Citrus Health Care 2009 Formulary (List of Covered Drugs) › reports › cmsd › 2009 › ... · and/or step therapy restrictions on a drug or move a drug to a higher cost -sharing

Citrus Health Care

2009 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS

WE COVER IN THIS PLAN

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

S8465CHC0057MR01E CMS Approval: 10/2008

Last Updated 11/10/2009

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What is the Citrus Health Care Formulary? A formulary is a list of covered drugs selected by Citrus Health Care in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Citrus Health Care will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Citrus Health Care network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary change?

Generally, if you are taking a drug on our 2009 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2009 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 01/01/2009. To get updated information about the drugs covered by Citrus Health Care, please visit our Web site at www.citrushc.com or call Member Services at 1 -800-546-5677, 24 hours a day, seven days a week. TTY/TDD users should call 1-866-706-4757.

How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition

The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat.

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For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR AGENTS. If you know what your drug is used for, look for the category name in the list that begins on page number 68. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 68. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

Citrus Health Care covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Citrus Health Care requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Citrus Health Care before you fill your prescriptions. If you don’t get approval, Citrus Health Care may not cover the drug.

• Quantity Limits: For certain drugs, Citrus Health Care limits the amount of the

drug that Citrus Health Care will cover. For example, Citrus Health Care provides six tablets per month per prescription for Zomig. This may be in addition to a standard one month or three month supply.

• Step Therapy: In some cases, Citrus Health Care requires you to first try certain

drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Citrus Health Care may not cover drug B unless you try Drug A first. If Drug A does not work for you, Citrus Health Care will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7.

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You can ask Citrus Health Care to make an exception to these restrictions or limits. See the section, “How do I request an exception to the Citrus Health Care formulary?” on page 4 for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Member Services and ask if your drug is covered. If you learn that Citrus Health Care does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by Citrus Health Care. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Citrus Health Care.

• You can ask Citrus Health Care to make an exception and cover your drug. See

below for information about how to request an exception.

How do I request an exception to the Citrus Health Care Formulary? You can ask Citrus Health Care to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover your drug even if it is not on our formulary. • You can ask us to waive coverage restrictions or limits on your drug. For

example, for certain drugs, Citrus Health Care limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limits and cover more.

• You can ask us to provide a higher level of coverage for your drug. If your drug is

contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier subject to the tiering exceptions process instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier.

Generally, Citrus Health Care will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

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You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician’s supporting statement. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first ninety (90) days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary thirty (30) day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Exceptions are available for beneficiaries who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Examples of situations in which beneficiaries would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the Part D program are as follows:

i. For example if a beneficiary was discharged from the hospital and was provided a discharge list of medications based upon the formulary of the hospital.

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ii. Beneficiaries who end their skilled nursing facility Medicare Part A stay (where payment s include all pharmacy charges) and who need to revert back to their Part D plan formulary

iii. Beneficiaries who give up Hospice Status to revert back to standard Medicare Part A and B benefits

iv. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized.

All of these situations would warrant a temporary one-time fill exception irregardless of if the beneficiary is in their first ninety (90) days of program enrollment. For more information For more detailed information about your Citrus Health Care prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Citrus Health Care, please call Customer Service at 1 -877-624-8787, 8am – 8pm EST Monday - Friday. TTY/TDD users should call 1-888-248-7875. Or visit www.citrushc.com. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.

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Citrus Health Care Formulary The formulary below provides coverage information about some of the drugs covered by Citrus Health Care. If you have trouble finding your drug in the list, turn to the Index that begins on page 68. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Requirements/Limits column tells you if Citrus Health Care has any special requirements for coverage of your drug. DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ANALGESICS Opioid Analgesics acetaminophen/codeine 1 Oral Solution

acetaminophen/codeine 1 Quantity Limitation - 400 tablets per 30 days

acetaminophen/codeine #2 1 Quantity Limitation - 400 tablets per 30 days



ascomp/codeine 1 Quantity Limitation BALACET 325 2 Quantity Limitation

buprenorphine hcl 2 Prior Authorization Required; Injectable dosage Formulation

butal/asa/caff/cod 2 Quantity Limitation butalbital/apap/caffeine/codeine 2

butorphanol tartrate 2 Prior Authorization Required; Quantity Limitation - 2 per 30 days

co-gesic 2 Quantity Limitation - 240 tablets per 30 days

dolorex forte 2 Quantity Limitation - 240 capsules per 30 days

endocet 2 Quantity Limitation - 360 tablets per 30 days

fentanyl 2 Quantity Limitation - 30 patches per 30 days; Transdermal Dosage Formulation

hydrocodone bitartrate/acetaminophen 2 Quantity Limitation - Not to exceed

4,000mg of acetaminophen/day

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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

hydrocodone/acetaminophen 2 Quantity Limitation - Not to exceed 4,000mg of acetaminophen/day

hydrocodone/acetaminophen-hs 2 Quantity Limitation - Not to exceed 4,000mg of acetaminophen/day

hydrocodone/ibuprofen 1 Quantity Limitation - 480 tablets per 30 days

hydromorphone hcl 2

KADIAN 3 Quantity Limitation - 60 capsules per 30 days; Step Therapy Protocols Apply

levorphanol tartrate 2

margesic-h 2 Quantity Limitation - 240 capsules per 30 days

meperidine hcl 2 meperitab 2

METHADONE HCL 4 Prior Authorization Required; Injectable dosage Formulation

methadone hcl 2 methadose 2 morphine sulfate 2

morphine sulfate 4 Prior Authorization Required; Injectable dosage Formulation

morphine sulfate er 2

nalbuphine hcl 4 Prior Authorization Required; Injectable dosage Formulation

narvox 1

NUCYNTA 4 Quantity Limitation - 180 tablets per 30 days

oxycodone hcl 2

oxycodone/acetaminophen 2 Quantity Limitation - Not to exceed 4,000mg of acetaminophen/day

oxycodone/aspirin 2 Quantity Limitation - 360 tablets per 30 days

oxycodone/ibuprofen 2

pentazocine/acetaminophen 2 Quantity Limitation - 180 tablets per 30 days

pentazocine/naloxone hcl 2 phrenilin w/caffeine/codeine 1 propoxyphene hcl 2

propoxyphene/acetaminophen 2 Quantity Limitation - Not to exceed 4,000mg of acetaminophen/day

propoxyphene-n/acetaminophen 2 Quantity Limitation - Not to exceed 4,000mg of acetaminophen/day

roxicet 2 Quantity Limitation - 360 per 30

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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS days on 325mg, 240 per 30 days on 500mg

stagesic 2 Quantity Limitation - 240 capules per 30 days

SUBOXONE 4 SUBUTEX 4

tramadol hcl 1 Quantity Limitation - 240 tablets per 30 days

tramadol hydrochloride/acetaminophen 1 Quantity Limitation - 240 tablets

per 30 days trezix 1

vanacet 2 Quantity Limitation - 240 tablets per 30 days

zerlor 1 acetaminophen/codeine 1 Oral Solution Nonsteriodal Anti-Inflammatory Drugs

CELEBREX 3 Step Therapy Protocols Apply; Quantity Limitation - 60 capsules per 30 days

diclofenac potassium 2 diclofenac sodium 2 diclofenac sodium dr 2 diclofenac sodium ec 2 diclofenac sodium er 2 diclofenac sodium xr 2 diflunisal 2 fenoprofen calcium 2 flurbiprofen 2 ibuprofen 1 indomethacin 1 indomethacin er 1

ketorolac tromethamine 2 Prior Authorization Required; Quantity Limitation - 20 tablets per 30 days

meclofenamate sodium 2

meloxicam 2 Quantity Limitation - 30 tablets per 30 days, 180ml per 30 days on 7.5mg/5ml suspension

nabumetone 2 naproxen 1 naproxen dr 1 naproxen sodium 1 oxaprozin 2 piroxicam 2

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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS sulindac 2 tolmetin sodium 2

ANESTHETICS Local Anesthetics lidocaine hcl 2 Topical Dosage Formulation lidocaine hcl jelly 1

lidocaine/prilocaine 2 Quantity Limitation - 30 grams per prescription; Topical Dosage Formulation

lidomar viscous 1

ANTIBACTERIALS Aminoglycosides ak-tob 2 genoptic 1 gentak 1 gentamicin sulfate 1

gentamicin sulfate 2 Prior Authorization Required; Injectable dosage Formulation

gentamicin sulfate 2 Topical Dosage Formulation GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE 2 Prior Authorization Required;

Injectable dosage Formulation gentasol 1 NEO-FRADIN 4 neomycin sulfate 2 paromomycin sulfate 1 tobramycin sulfate 2

tobramycin sulfate 4 Prior Authorization Required; Injectable dosage Formulation

tobrasol 2 Antibacterials, Other ak-poly-bac 2 bacitracin 2 bacitracin/neomycin/polymyxin 2 bacitracin/polymyxin b 2 clindamycin hcl 1 clindamycin phosphate 2

clindamycin phosphate 2 Prior Authorization Required; Injectable dosage Formulation

clindamycin phosphateadd-vantage 2 Prior Authorization Required;

Injectable dosage Formulation

colistimethate sodium 2 Prior Authorization Required; Injectable dosage Formulation

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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS erythromycin/sulfisoxazole 1 methenamine hippurate 2 metronidazole 1 metronidazole vaginal 2 Vaginal Dosage Formulation mupirocin 2 Topical Dosage Formulation neomycin/bacitracin zn/polymyx 2 neomycin/bacitracin/polymyxin 2 neomycin/polymyxin/gramicidin 2 nitrofurantoin macrocrystalline 1 nitrofurantoin monohydrate 1 polycin b 2 polymyxin b sulfate/trimethoprim sulfate 2

trimethoprim 2 trimethoprim sulfate/polymyxin b sulfate

2

VANCOCIN HCL 4 Prior Authorization Required; Injectable dosage Formulation

VANCOCIN HCL 5 Prior Authorization Required; Oral dosage formulation

VANCOCIN HCL ISO-OSMOTICDEXTROSE 4 Prior Authorization Required;


vancomycin hcl 4 Prior Authorization Required; Injectable dosage Formulation

vandazole 1

ZYVOX 5 Prior Authorization Required; Injectable dosage Formulation

ZYVOX 5 Prior Authorization Required; Quantity Limitation

Beta-lactam, Cephalosporins cefaclor 1 cefaclor er 1 cefadroxil 2

CEFAZOLIN SODIUM 4 Prior Authorization Required; Injectable dosage Formulation

cefdinir 2

cefepime 2 Prior Authorization Required; Injectable dosage Formulation

CEFOTAXIME SODIUM 2 Prior Authorization Required; Injectable dosage Formulation

cefoxitin sodium 4 Prior Authorization Required; Injectable dosage Formulation

cefpodoxime proxetil 2 cefprozil 2

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ceftriaxone sodium 4 Prior Authorization Required; Injectable dosage Formulation

cefuroxime axetil 2 cephalexin 1

MAXIPIME 4 Prior Authorization Required; Injectable dosage Formulation

Beta-lactam, Other

AZACTAM 3 Prior Authorization Required; Injectable dosage Formulation

AZACTAM IN DEXTROSE 3 Prior Authorization Required; Injectable dosage Formulation

INVANZ 4 Prior Authorization Required; Injectable dosage Formulation

MERREM 3 Beta-lactam, Penicillins amoclan 2 amoxicillin 1 amoxicillin/clavulanate potassium 2

amoxil 1 ampicillin 1

AMPICILLIN SODIUM 2 Prior Authorization Required; Injectable dosage Formulation

ampicillin-sulbactam 1 Prior Authorization Required; Injectable dosage Formulation

dicloxacillin sodium 1

NAFCILLIN SODIUM 4 Prior Authorization Required; Injectable dosage Formulation

penicillin g potassium 4 Prior Authorization Required; Injectable dosage Formulation

PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE

4 Prior Authorization Required; Injectable dosage Formulation

PENICILLIN G PROCAINE 4 Prior Authorization Required; Injectable dosage Formulation

PENICILLIN G SODIUM 4 Prior Authorization Required; Injectable dosage Formulation

penicillin v potassium 1

PIPERACILLIN SODIUM 4 Prior Authorization Required; Injectable dosage Formulation

trimox 1 veetids 1 Macrolides azithromycin 2 Prior Authorization Required;


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azithromycin 2 Quantity Limitation - 6 tablets per prescription

clarithromycin 2 Quantity Limitation - 28 tablets per prescription

clarithromycin er 1 Quantity Limitation - 28 tablets per prescription

e.e.s. 200 1 e.e.s. 400 1 eryderm 2 Topical Dosage Formulation ery-tab 1

ERYTHROCIN 4 Prior Authorization Required; Injectable dosage Formulation

ERYTHROCIN LACTOBIONATE


erythrocin stearate 1 erythromycin 1 erythromycin 2 Ophthalmic Dosage Formualtion erythromycin 2 Topical Dosage Formulation erythromycin base 1 erythromycin ethylsuccinate 1 ERYTHROMYCIN LACTOBIONATE 4 Prior Authorization Required;

Injectable dosage Formulation romycin 2 ZMAX 3 Quinolones AVELOX 4 Prior Authorization Required;


AVELOX 4 Quantity Limitation - 14 tablets per prescription

AVELOX ABC PACK 4 Quantity Limitation - 14 tablets per prescription

BESIVANCE 4

ciprofloxacin 2 Prior Authorization Required; Injectable dosage Formulation

ciprofloxacin er 1 ciprofloxacin hcl 1 ciprofloxacin hcl 2 Ophthalmic Dosage Formualtion ofloxacin 1 Otic Solution ofloxacin 2 Sulfonamides GANTRISIN PEDIATRIC 4 ocusulf-10 1 sodium sulfacetamide 2 Topical Dosage Formulation sulf-10 1

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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS sulfacetamide sodium 1 sulfadiazine 2 sulfamethoxazole/trimethoprim 1

sulfamethoxazole/trimethoprim 4 Prior Authorization Required; Injectable dosage Formulation

sulfamethoxazole/trimethoprim ds 1

sulfatrim 1 trimethoprim/sulfamethoxazole ds

1

Sulfanamides silver sulfadiazine 1 Topical Dosage Formulation ssd 1 Topical Dosage Formulation ssd af 1 Topical Dosage Formulation SULFAMYLON 4 Topical Dosage Formulation thermazene 1 Topical Dosage Formulation Tetracyclines demeclocycline hcl 2 doxy-caps 1

DOXYCYCLINE HYCLATE 2 Prior Authorization Required; Injectable dosage Formulation

doxycycline hyclate 1 doxycycline monohydrate 1 minocycline hcl 2 myrac 2 tetracycline hcl 1

ANTICONVULSANTS Anticonvulsants, Other

BANZEL 4 Quantity Limitation – 240 tablets per 30 days

KEPPRA 4

KEPPRA 4 Prior Authorization Required; Injectable dosage Formulation

KEPPRA XR 4 Quantity Limitation – 180 tablets per 30 days

Calcium Channel Modifying Agents CELONTIN 4 ethosuximide 2

LYRICA 3 Quantity Limitation- 120 per 30 days

zonisamide 2 Gamma-aminobutyric Acid (GABA) Augmenting Agents DEPACON 4 Prior Authorization Required;

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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Injectable dosage Formulation

DEPAKOTE 3 DEPAKOTE SPRINKLES 3

gabapentin 2

Quantity Limitation - 120 per 30 days on 800mg; 180 per 30 days on 600mg; 270 per 30 days on 400mg; 360 per 30 days on 100mg and 300mg

GABITRIL 4 NEURONTIN 4 primidone 2 STAVZOR 5 valproate sodium 4 Injectable dosage Formulation valproic acid 2 Glutamate Reducing Agents FELBATOL 4

LAMICTAL 4 Quantity Limitation - 90 tablets per 30 days

LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE 4 Quantity Limitation - 90 tablets per

30 days LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE

4 Quantity Limitation - 90 tablets per 30 days

LAMICTAL STARTER/TAKING VALPROATE

4 Quantity Limitation - 90 tablets per 30 days

LAMICTAL XR 4 Quantity Limitation - 30 tablets per 30 days

lamotrigine chewable dispersible 2 Quantity Limitation - 600 tablets per 30 days

TOPAMAX 3 TOPAMAX SPRINKLE 3 topiramate 1 topiramate sprinkle 2 Sodium Channel Inhibitors carbamazepine 1 CARBATROL 4

CEREBYX 4 Prior Authorization Required; Injectable dosage Formulation

DILANTIN 4 DILANTIN INFATABS 4 epitol 1

fosphenytoin sodium 4 Prior Authorization Required; Injectable dosage Formulation

oxcarbazepine 1

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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS PEGANONE 4 PHENYTEK 4 phenytoin 1

phenytoin sodium 4 Prior Authorization Required; Injectable dosage Formulation

phenytoin sodium extended 1 TEGRETOL-XR 4 TRILEPTAL 4

VIMPAT 4 Quantity Limitation - 60 tablets per 30 days

VIMPAT SOLUTION 4 Quantity Limitation – 1200mls per 30 days

ANTIDEMENTIA AGENTS Antidementia Agents, Other ergoloid mesylates 2 Cholinesterase Inhibitors

ARICEPT 3 Quantity Limitation - 30 tablets per 30 days

ARICEPT ODT 3 Quantity Limitation - 30 tablets per 30 days

COGNEX 4 Quantity Limitation - 120 capsules per 30 days

EXELON 3 Quantity Limitation - 180mls per month

EXELON 3 Quantity Limitation - 60 capsules per 30 days

EXELON 3 Transdermal Patches

galantamine 2 Quantity Limitation – 180ml per 30 days on 4mg/ml solution

galantamine er 2 Quantity Limitation – 30 capsules per 30 days

RAZADYNE 4

Quantity Limitation - 60 tablets per 30 days, 180ml per 30 days on 4mg/ml solution

RAZADYNE ER 4 Quantity Limitation - 30 capsules per 30 days

Glutamate Pathway Modifiers

NAMENDA 3 Quantity Limitation - 360ml per 30 days

NAMENDA 3 Quantity Limitation - 60 tablets per 30 days

NAMENDA TITRATION PAK 3 Quantity Limitation - 60 tablets per 30 days

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ANTIDEPRESSANTS Antidepressants, Other amoxapine 2

APLENZIN 4 Quantity Limitation – 30 tablets per 30 days

budeprion sr 2

budeprion xl 2 Quantity Limitation - 30 tablets per 30 days

bupropion hcl 2 bupropion hcl sr 2 chlordiazepoxide/amitriptyline 1 maprotiline hcl 2

mirtazapine 2 Quantity Limitation - 30 tablets per 30 days

nefazodone hcl 2 perphenazine/amitriptyline 1 trazodone hcl 1 Monoamine Oxidase Inhibitors

EMSAM

4

Prior Authorization Required; Quantity Limitation - 30 patches per 30 days; Transdermal Dosage Formulation

MARPLAN 4 NARDIL 4 tranylcypromine sulfate 2 Serotonin/ Norepinephrine Reuptake Inhibitors citalopram hydrobromide 1

CYMBALTA 3 Quantity Limitation - 30 capsules per 30 days on 30mg and 60mg; 60 capsules per 30 days on 20mg

EFFEXOR XR 4

Quantity Limitation - 180 capsules per 30 days on 37.5mg; 90 capsules per 30 days on 75mg; 60 capsules per 30 days on 150mg

fluoxetine hcl 1

fluvoxamine maleate 2

Quantity Limitation - 60 tablets per 30 days on 50mg; 45 tablets per 30 days on 25mg; 90 tablets per 30 days on 100mg

LEXAPRO 4 Quantity Limitation - 30 tablets per 30 days, 620ml per 30 days on 5mg/5ml solution

paroxetine hcl 2 Quantity Limitation - 30 tablets per

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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS 30 days, 946ml per 30 days on 10mg/5ml suspension

PAXIL CR 4 Quantity Limitation - 90 tablets per 30 days on 12.5mg and 25mg; 60 tablets per 30 days on 37.5mg

PRISTIQ 4

sertraline hcl 2

Quantity Limitation - 30 per 30 days on 25mg and 50mg, 60 per 30 days on 100mg 300ml per 30 days on 20mg/ml solution

venlafaxine hcl 2

Quantity Limitation - 150 tablets per 30 days on 75mg; 90 tablets per 30 days on 37.5mg, 50mg, 100mg

Tricyclics amitriptyline hcl 1 clomipramine hcl 2 desipramine hcl 2 doxepin hcl 1 imipramine hcl 2 nortriptyline hcl 1 SURMONTIL 4 trimipramine maleate 2 VIVACTIL 4

ANTIDOTES, DETERRENTS, AND TOXICOLOGIC AGENTS

Antidotes ACETADOTE 4 Prior Authorization Required;


ANTIZOL 5 Prior Authorization Required; Injectable dosage Formulation

CUPRIMINE 4 Prior Authorization Required DEPEN TITRATABS 4 Prior Authorization Required EXJADE 5 Prior Authorization Required KAYEXALATE 4 KIONEX 4 sodium polystyrene sulfonate 1 sps 1 SYPRINE 4 Deterrents ANTABUSE 4 BUPROBAN 2 CHANTIX 4 Quantity Limitation

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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS NICOTINE 1

NICOTROL NS 4 Quantity Limitation - 4 inhalers per 30 days

Toxicologic Agents LEUCOVORIN CALCIUM 4 Prior Authorization Required;

Injectable dosage Formulation LEUCOVORIN CALCIUM 4 Prior Authorization Required; Oral MESNEX 5

ANTIEMETICS Antiemetics chlorpromazine hcl 1 chlorpromazine hcl 1 Injectable dosage Formulation diphenhydramine hcl 1

EMEND 4 Prior Authorization Required; Quantity Limitation - 5 capsules per prescription

granisetron hcl 2 Prior Authorization Required; Quantity Limitation 10 per prescription

granisol 2 Prior Authorization Required hydroxyzine pamoate 1 meclizine hcl 1 metoclopramide hcl 1

ondansetron hcl 1

Prior Authorization Required; Quantity Limitation - 10 tablets per prescription; 50ml oral solution per prescription

ondansetron odt 1

Prior Authorization Required; Quantity Limitation - 10 tablets per prescription; 50ml oral solution per prescription

perphenazine 1 prochlorperazine edisylate 2 prochlorperazine maleate 2 trimethobenzamide hcl 2

ANTIFUNGALS Antifungals ABELCET 5 Prior Authorization Required;


amphotericin b 4 Prior Authorization Required; Injectable dosage Formulation

ANCOBON 4

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CANCIDAS 5 Prior Authorization Required; Injectable dosage Formulation

ciclopirox 2 Topical Dosage Formulation ciclopirox nail lacquer 1 Topical Dosage Formulation ciclopirox olamine 2 Topical Dosage Formulation clotrimazole 1 clotrimazole 2 Topical Dosage Formulation econazole nitrate 2 Topical Dosage Formulation

ERAXIS 4 Prior Authorization Required; Injectable dosage Formulation

EXELDERM 4 Topical Dosage Formulation fluconazole 2 GRIFULVIN V 4 griseofulvin microsize 4 GYNAZOLE-1 4 itraconazole 2 ketoconazole 2 kuric 2 Topical Dosage Formulation

LAMISIL 3 Quantity Limitation - 30 grams per 30 days; Topical Dosage Formulation

LOPROX 4 Topical Dosage Formulation LOPROX SHAMPOO 4 Topical Dosage Formulation miconazole 3 2 Vaginal Dosage Formulation NAFTIN 4 Topical Dosage Formulation NAFTIN-MP 4 Topical Dosage Formulation NATACYN 4 nyamyc 2 Topical Dosage Formulation nystatin 1 nystatin/triamcinolone 1 Topical Dosage Formulation nystop 2 Topical Dosage Formulation pedi-dri 2 Topical Dosage Formulation terbinafine hcl 2 terconazole 2 VFEND 5 Prior Authorization Required

VFEND IV 5 Prior Authorization Required; Injectable dosage Formulation

zazole 1

ANTIGOUT AGENTS Antigout Agents allopurinol 1 colchicine 1 probenecid 2

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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS probenecid/colchicine 2

ANTI-INFLAMMATORY AGENTS Glucocorticoids

a-methapred 4 Prior Authorization Required; Injectable dosage Formulation

CELESTONE 4 cortisone acetate 1 dexamethasone 1 ENTOCORT EC 3 hydrocortisone 1 methylprednisolone 1

methylprednisolone acetate 4 Prior Authorization Required; Injectable dosage Formulation

methylprednisolone sodiumsuccinate 2 Prior Authorization Required;

Injectable dosage Formulation methylprednisolone sodiumsuccinate


prednisolone 2 prednisolone sodium phosphate 2 prednisone 1 prednisone intensol 1

ANTIMIGRAINE AGENTS Abortive ergotamine tartrate/caffeine 2

IMITREX 3 Quantity Limitation - 6 injections per 30 days; Injectable dosage Formulation

IMITREX 3 Quantity Limitation - 9 tablets per 30 days; 6 ml nasal spray per 30 days; 6 injections per 30 days

IMITREX STATDOSE REFILL 3 Quantity Limitation - 6 injections per 30 days; Injectable dosage Formulation

migergot 2

RELPAX 3 Quantity Limitation - 6 tablets per 30 days

sumatriptan 1 Quantity Limitation - 6 injections per 30 days; Injectable dosage Formulation

sumatriptan 1 Quantity Limitation - 9 tablets per 30 days; 6 ml nasal spray per 30 days; 6 injections per 30 days

22


ZOMIG 3 Quantity Limitation - 6 tablets per 30 days; 6ml nasal spray per 30 days

ZOMIG ZMT 3 Quantity Limitation - 6 tablets per 30 days

Prophylactic DEPAKOTE ER 3 timolol maleate 2

ANTIMYASTHENIC AGENTS Parasympathomimetics GUANIDINE HCL 3 MESTINON 4 MESTINON TIMESPAN 4 MYTELASE 4 pyridostigmine bromide 2

ANTIMYCOBACTERIALS Antimycobacterials, Other DAPSONE 3 MYCOBUTIN 4 Antituberculars CAPASTAT SULFATE 4 Prior Authorization Required;

Injectable dosage Formulation ethambutol hcl 2 isonarif 1 isoniazid 1 PRIFTIN 4 pyrazinamide 1 RIFAMATE 4 rifampin 2

rifampin 4 Prior Authorization Required; Injectable dosage Formulation

RIFATER 4 SEROMYCIN 4 TRECATOR 4

ANTINEOPLASTICS Alkylating Agents EMCYT 5 Prior Authorization Required CEENU 4 Prior Authorization Required HEXALEN 5 Prior Authorization Required LEUKERAN 2 Prior Authorization Required MATULANE 4

23


ZANOSAR 4 Prior Authorization Required; Injectable dosage Formulation

Antiangiogenic Agents

REVLIMID 5

Prior Authorization Required; This prescription may be available only at certain pharmacies. For more information call Member Services at 1-800-546-5677, 24 hours a day, seven days a week. TTY/TDD users should call 1-866-706-4757.

THALOMID 5 Prior Authorization Required Antiestrogens/Modifiers FARESTON 4 SOLTAMOX 4 tamoxifen citrate 1 Antimetabolites DROXIA 4 hydroxyurea 2 mercaptopurine 2 TABLOID 4 Prior Authorization Required Antineoplastics, Other

ARRANON 5 Prior Authorization Required; Injectable dosage Formulation

bleomycin sulfate 2 Prior Authorization Required; Injectable dosage Formulation

cyclophosphamide 2 Prior Authorization Required

ELITEK 5 Prior Authorization Required; Injectable dosage Formulation

mitoxantrone hcl 5 Prior Authorization Required; Injectable dosage Formulation

ONTAK 5 Prior Authorization Required; Injectable dosage Formulation

PROLEUKIN 5 Prior Authorization Required; Injectable dosage Formulation

tretinoin 2

TRISENOX 4 Prior Authorization Required; Injectable dosage Formulation

TYKERB 5 Prior Authorization Required

VELCADE 5 Prior Authorization Required; Injectable dosage Formulation

VIDAZA 5 Prior Authorization Required; Injectable dosage Formulation

ZOLINZA 5 Aromatase Inhibitors, 3rd Generation

24


ARIMIDEX 3 Quantity Limitation - 30 tablets per 30 days

AROMASIN 3 FEMARA 4 Molecular Target Inhibitors

AFINITOR 5 Quantity Limitation – 60 tablets per 30 days

GLEEVEC 5

Prior Authorization Required - Quantity Limitation - 90 tablets per 30 days on 100mg, 60 tablets per 30 days on 400mg

IRESSA 5

Prior Authorization Required; Quantity Limitation - 30 tablets per 30 days

NEXAVAR 5

Prior Authorization Required; Quantity Limitation 120 per 30 days

SPRYCEL 5 Prior Authorization Required SUTENT 5 Prior Authorization Required TARCEVA 5 Prior Authorization Required TASIGNA 5 Monoclonal Antibodies

AVASTIN 5 Prior Authorization Required; Injectable dosage Formulation

CAMPATH 5 Prior Authorization Required; Injectable dosage Formulation

HERCEPTIN 5 Prior Authorization Required; Injectable dosage Formulation

MYLOTARG 5 Prior Authorization Required; Injectable dosage Formulation

RITUXAN 5 Prior Authorization Required; Injectable dosage Formulation

Retinoids

PANRETIN 5 Prior Authorization Required; Topical Dosage Formulation

TARGRETIN 5 Prior Authorization Required

TARGRETIN 5

Prior Authorization Required; Quantity Limitation - 60 grams per prescription; Topical Dosage Formulation

ANTIPARASITICS Anthelmintics BILTRICIDE 4

25

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS mebendazole 2 MINTEZOL 4 STROMECTOL 4 Prior Authorization Required Antiprotozoals ALINIA 4 chloroquine phosphate 2 DARAPRIM 4 FANSIDAR 4 hydroxychloroquine sulfate 1 MALARONE 4 mefloquine hcl 2 MEPRON 4 Prior Authorization Required

NEUTREXIN 5 Prior Authorization Required; Injectable dosage Formulation

PRIMAQUINE PHOSPHATE 4 TINDAMAX 4 Pediculicides/Scabicides acticin 1 Topical Dosage Formulation lindane 2 lindane 2 Topical Dosage Formulation OVIDE 4 Topical Dosage Formulation permethrin 1 Topical Dosage Formulation

ANTIPARKINSON AGENTS Antiparkinson Agents amantadine hcl 1

APOKYN 5 Prior Authorization Required; Injectable dosage Formulation

atamet 1 AZILECT 4 benztropine mesylate 2 bromocriptine mesylate 2 carbidopa/levodopa 1 carbidopa/levodopa cr 1 carbidopa/levodopa er 1 carbidopa/levodopa odt 2 carbidopa/levodopa sr 1

COMTAN 3 Quantity Limitation - 240 tablets per 30 days

KEMADRIN 4 LODOSYN 4

MIRAPEX 3 Quantity Limitation - 90 tablets per 30 days

REQUIP 3

26

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS REQUIP XL 3 selegiline hcl 2 STALEVO 100 3 STALEVO 150 3 STALEVO 200 3 STALEVO 50 3

TASMAR 4 Quantity Limitation - 90 tablets per 30 days

trihexyphenidyl hcl 2

ANTIPSYCHOTICS Atypicals ABILIFY 4 Prior Authorization Required;


ABILIFY 4 Quantity Limitation - 30 tablets per 30 days

ABILIFY 4 Quantity Limitation - 900mls per month

ABILIFY DISCMELT 4 Quantity Limitation - 60 tablets per 30 days

clozapine 2 Quantity Limitation - 120 tablets per 30 days

FAZACLO 4 Quantity Limitation - 270 tablets per 30 days

GEODON 3 Quantity Limitation - 60 capsules per 30 days

GEODON 4 Injectable dosage Formulation

INVEGA 4

Prior Authorization Required; Quantity Limitation - 30 tablets per 30 days on 3mg and 9mg, 60 tablets per 30 days on 6mg

RISPERDAL 4

Quantity Limitation - 60 tablets per 30 days on all strengths except 4mg, 120 tablets per 30 days on 4mg 480ml per 30 days on 1mg/ml solution

RISPERDAL CONSTA 4 Prior Authorization Required; Injectable dosage Formulation

RISPERDAL M-TAB 4 Quantity Limitation - 60 tablets per 30 days, 120 tablets per 30 days on 2mg

risperidone 2 Quantity Limitation 480ml per 30 days on 1mg/ml solution; Solution dosage formulation

27


SEROQUEL 3

Quantity Limitation - 60 per 30 days on 400mg, 90 per 30 days on 200mg and 300mg, 120 per 30 days on 25mg and 50mg and 100mg

SEROQUEL XR 3 Quantity Limitation - 60 tablets per 30 days on 300mg and 400mg; 30 tablets per 30 days on 200mg

SYMBYAX 3 Quantity Limitation - 30 capsules per 30 days

ZYPREXA 3 Prior Authorization Required; Injectable dosage Formulation; Quantity Limitation

ZYPREXA 3 Quantity Limitation - 30 tablets per 30 days

ZYPREXA ZYDIS 3 Quantity Limitation - 30 tablets per 30 days

Conventional compro 2 fluphenazine decanoate 4 fluphenazine hcl 1 Injectable dosage formulation fluphenazine hcl 2 haloperidol 2

haloperidol decanoate 4 Prior Authorization Required; Injectable dosage Formulation

haloperidol lactate 4 loxapine succinate 2 MOBAN 4 NAVANE 4 ORAP 4 prochlorperazine 2 thioridazine hcl 2 thiothixene 2 trifluoperazine hcl 2

ANTISPASTICITY AGENTS Antispasticity Agents baclofen 1 dantrolene sodium 2 tizanidine hcl 2 Quantity Limitation

ANTIVIRALS Anti-cytomegalovirus (CMV) Agents CYTOVENE 4

28

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS foscarnet sodium 5 FOSCAVIR 5 ganciclovir 2 VALCYTE 5 VISTIDE 5 Antihepatitis Agents

BARACLUDE 5 Prior Authorization Required; Quantity Limitation - 30 tablets per 30 days

HEPSERA 5 Prior Authorization Required; Injectable dosage Formulation

ribasphere 2 ribavirin 2 TYZEKA 4 Prior Authorization Required Antiherpetic Agents acyclovir 1 famciclovir 2 trifluridine 2 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors INTELENCE 4 RESCRIPTOR 4 SUSTIVA 3 VIRAMUNE 3 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors ATRIPLA 4 COMBIV IR 3 didanosine 2 EMTRIVA 4 EPIVIR 3 EPIVIR HBV 3 EPZICOM 3 RETROVIR IV INFUSION 4 Injectable dosage Formulation stavudine 2 TRIZIVIR 3 TRUVADA 3 VIDEX 4 VIDEX EC 4 VIREAD 4 ZERIT 4 ZIAGEN 3 zidovudine 2 Anti-HIV Agents, Other FUZEON 5 FUZEON ISENTRESS 5 ISENTRESS

29

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS SELZENTRY 5 SELZENTRY Anti-HIV Agents, Protease Inhibitors APTIVUS 4 APTIVUS

APTIVUS SOLUTION 4 Quantity Limitation – 300mls per 30 days

CRIXIVAN 4 CRIXIVAN INVIRASE 4 INVIRASE KALETRA 3 KALETRA LEXIVA 3 LEXIVA NORVIR 4 NORVIR PREZISTA 4 PREZISTA REYATAZ 4 REYATAZ VIRACEPT 4 VIRACEPT Anti-influenza Agents RELENZA 5 Quantity Limitation-1 inhaler per

180 days rimantadine hcl 1 TAMIFLU 3

ANXIOLYTICS Anxiolytics, Other buspirone hcl 1 meprobamate 2

BIPOLAR AGENTS Bipolar Agents lithium carbonate 1 lithium carbonate er 1 lithium citrate 1

BLOOD GLUCOSE REGULATORS Antidiabetic Agents ACTOPLUS MET 4 Quantity Limitation - 90 tablets per

30 days

ACTOS 4 Quantity Limitation - 30 tablets per 30 days

AVANDAMET 3 Quantity Limitation - 60 tablets per 30 days

AVANDARYL 3 Quantity Limitation - 60 tablets per 30 days

AVANDIA 3 Quantity Limitation - 60 tablets per 30 days

BYETTA 4 Quantity Limitation - 1 kit per 30 days; Injectable dosage

30

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Formulation

chlorpropamide 1 glimepiride 2 glipizide 1 glipizide er 1 glipizide xl 1 glipizide/metformin hcl 2 glyburide 1 glyburide micronized 1 glyburide/metformin hcl 2 glycron 1 GLYSET 4 Step Therapy Protocols Apply JANUMET 4 Step Therapy Protocols Apply

JANUVIA 4 Step Therapy Protocols Apply; Quantity Limitation - 30 tablets per 30 days

metformin hcl 1 metformin hcl er 1

PRANDIN 4 Quantity Limitation - 240 tablets per 30 days

PRECOSE 4 Step Therapy Protocols Apply

SYMLIN 4 Quantity Limitation - 20ml per 30 days; Injectable dosage Formulation

tolazamide 2 tolbutamide 2 Blood Glucose Regulators, Misc ALCOHOL SWABS 3 ALCOHOL SWABS DIABETIC SUPPLIES, MISC 3 DIABETIC SUPPLIES, MISC Glycemic Agents

GLUCAGEN HYPOKIT 3 Prior Authorization Required; Injectable dosage Formulation

GLUCAGON EMERGENCY KIT 3 Prior Authorization Required; Injectable dosage Formulation

PROGLYCEM 4 Insulins

APIDRA 4

Quantity Limitation - 30ml (3 vials) per 30 days; Injectable dosage Formulation

HUMALOG 3

Quantity Limitation - 30ml per 30 days; Injectable dosage Formulation

HUMALOG MIX 50/50 3 Quantity Limitation - 30ml per 30 days; Injectable dosage

31


HUMALOG MIX 50/50 PEN 3


HUMALOG MIX 75/25 3


HUMALOG MIX 75/25 PEN 3


HUMALOG PEN 3


HUMULIN 50/50 3


HUMULIN 70/30 3


HUMULIN 70/30 PEN 3


HUMULIN N 3


HUMULIN N U-100 PEN 3


HUMULIN R 3


LANTUS 4


LANTUS SOLOSTAR 4 Quantity Limitation 30ml per 30 days

LEVEMIR 4

Quantity Limitation - 10ml (1 vial ) per 30 days; Injectable dosage Formulation

LEVEMIR FLEXPEN 4

Quantity Limitation - 12ml (4 flexpens) per 30 days; Injectable dosage Formulation

NOVOLIN 70/30 3


32


NOVOLIN 70/30 INNOLET 3


NOVOLIN 70/30 PENFILL 3


NOVOLIN N 3


NOVOLIN N INNOLET 3


NOVOLIN N U-100 PENFILL 3


NOVOLIN R 3


NOVOLIN R INNOLET 3


NOVOLIN R U-100 PENFILL 3


NOVOLOG 3


NOVOLOG MIX 70/30 3


NOVOLOG MIX 70/30 PENFILL 3


NOVOLOG MIX 70/30 PREFILLED FLEXPEN 3


NOVOLOG PENFILL 3


RELION 70/30 3


RELION 70/30 INNOLET 3


33


RELION N 3


RELION N INNOLET 3


RELION R 3


BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS

Anticoagulants

ARIXTRA 5 Prior Authorization Required; Injectable dosage Formulation; Quantity Limitation

COUMADIN 3 Prior Authorization Required; Injectable dosage Formulation

COUMADIN 3

FRAGMIN 4 5000 and 2500 unit Injectable dosage Formulation

FRAGMIN 5 7500, 10000 and 25000 unit; Injectable dosage Formulation

HEPARIN SODIUM 4 Prior Authorization Required; Injectable dosage Formulation

HEPARIN SODIUM DCU 4 Prior Authorization Required; Injectable dosage Formulation

HEPARIN SODIUM/NACL 0.45% 4 Prior Authorization Required;


heparin sodium/nacl 0.9% 4 Prior Authorization Required; Injectable dosage Formulation

INNOHEP 4 Prior Authorization Required; Injectable dosage Formulation

jantoven 1

LOVENOX 5 100mg, 60mg, 300mg, 150mg, 120mg, 80mg Injectable dosage Formulation; Quantity Limitation

LOVENOX 5 40mg and 30mg Injectable dosage Formulation; Quantity Limitation

warfarin sodium 1 Blood Formation Products

ARANESP ALBUMIN FREE 4

25mcg; Prior Authorization Required; Injectable dosage Formulation; Quantity Limitation

34


ARANESP ALBUMIN FREE 5

Prior Authorization Required; Injectable dosage Formulation; Quantity Limitation

ARANESP ALBUMIN FREE SURE 5

Prior Authorization Required; Injectable dosage Formulation; Quantity Limitation

EPOGEN 3

3000 unit strengths only; Quantity Limitation - 12 per 28 days; Prior Authorization Required; Injectable dosage Formulation

EPOGEN 4

2000, 4000 unit strengths only; Quantity Limitation - 12 per 28 days; Prior Authorization Required; Injectable dosage Formulation

EPOGEN 5

10000, 20000, 40000 unit strengths; Prior Authorization Required; Injectable dosage Formulation

NEULASTA 5 Prior Authorization Required; Injectable dosage Formulation

NEUMEGA 5 Prior Authorization Required; Injectable dosage Formulation

NEUPOGEN 5 Prior Authorization Required; Injectable dosage Formulation

PROCRIT 4

2000, 3000, 4000 unit strengths only; Quantity Limitation - 12 per 28 days; Prior Authorization Required; Injectable dosage Formulation

PROCRIT 5

10000, 20000, 40000 unit strengths; Prior Authorization Required; Injectable dosage Formulation

Coagulants CYKLOKAPRON 3 METHERGINE 5 RIASTAP 5 Prior Authorization Required Platelet Aggregation Inhibitors AGGRENOX 4 anagrelide hydrochloride 2 cilostazol 2 dipyridamole 1

EFFIENT 4 Quantity Limitation - 30 tablets per 30 days

pentopak 1

35

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS pentoxifylline er 1 pentoxil 1

PLAVIX 4 Quantity Limitation - 30 tablets per 30 days

ticlopidine hcl 2

CARDIOVASCULAR AGENTS Alpha-adrenergic Agonists clonidine hcl 1

clonidine hcl 2 Transdermal Dosage Formulation; Quantity Limitation 4 patches per 30 days

guanabenz acetate 2 guanfacine hcl 2 methyldopa 1 methyldopa/hydrochlorothiazide 1

methyldopate hcl 4 Prior Authorization Required; Injectable dosage Formulation

midodrine hcl 2 Alpha-adrenergic Blocking Agents doxazosin mesylate 1 prazosin hcl 1 reserpine 1 terazosin hcl 1 Antiarrhythmics acebutolol hcl 2 amiodarone hcl 2 cartia xt 2 dilt-cd 1 diltiazem cd 2 diltiazem hcl 2 diltiazem hcl er 2 dilt-xr 2 disopyramide phosphate 1 disopyramide phosphate er 1 flecainide acetate 2 mexiletine hcl 2 pacerone 2 200mg propafenone hcl 2 propranolol hcl 1 propranolol hcl er 1 quinidine gluconate cr 1 quinidine gluconate er 1 quinidine gluconate sa 1

36

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS quinidine sulfate 1 quinidine sulfate er 1 sorine 2 sotalol hcl 2 sotalol hcl (af) 2 taztia xt 2 TIKOSYN 4 verapamil hcl 2 verapamil hcl er 2 Beta-adrenergic Blocking Agents atenolol 1 atenolol/chlorthalidone 1 betaxolol hcl 2 bisoprolol fumarate 1 bisoprolol fumarate/hydrochlorothiazide 1

carvedilol 1

COREG CR 3 Quantity Limitation - 30 tablets per 30 days

EXFORGE 3 Quantity Limitation - 30 tablets per 30 days

labetalol hcl 2 LEVATOL 2

metoprolol succinate er 2 Quantity Limitation - 60 tablets per 30 days on 200mg; 30 tablets per 30 days on 100mg, 25mg, 50mg

metoprolol tartrate 1 metoprolol/hydrochlorothiazide 2 nadolol 2 nadolol/bendroflumethiazide 1 pindolol 2 propranolol/hydrochlorothiazide 1 Calcium Channel Blocking Agents afeditab cr 2

amlodipine besylate 1 Quantity Limitation - 30 tablets per 30 days

amlodipine besylate/benazepril hydrochloride

2 Quantity Limitation - 30 capsules per 30 days

isradipine 2 nicardipine hcl 2 nifediac cc 2 nifedical xl 2 nifedipine 2 nifedipine er 2

37

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS nimodipine 2 Cardiovascular Agents, Others

digitek 1

Quantity Limitation - 300ml of solution per 30 days; 120 tablet per 30 days on 0.125mg; 60 tablets per 30 days on 0.25mg

digoxin 1


INVERSINE 4

LANOXIN 3 Prior Authorization Required; Injectable dosage Formulation

LANOXIN 3


RANEXA 3 Quantity Limitation - 120 tablets per 30 days

Diuretics amiloride hcl 2 amiloride/hydrochlorothiazide 2 bumetanide 2 chlorothiazide 2 chlorthalidone 2 DYRENIUM 4 furosemide 1

furosemide 1 Prior Authorization Required; Injectable dosage Formulation

hydrochlorothiazide 1 indapamide 2

INSPRA 4

Prior Authorization Required; Quantity Limitation - 120 tablets per 30 days on 25mg and 60 tablets per 30 days on 50mg

methazolamide 2 methyclothiazide 2 metolazone 2 spironolactone 1 spironolactone/hydrochlorothiazide 2

torsemide 2 triamterene/hydrochlorothiazide 1 Dyslipidemics

38


CADUET 3 Quantity Limitation - 30 tablets per 30 days

cholestyramine 2 cholestyramine light 2 colestipol hcl 1

CRESTOR 3 Quantity Limitation - 30 tablets per 30 days

fenofibrate 2 gemfibrozil 1

LIPITOR 3 Quantity Limitation - 30 tablets per 30 days

lofibra 2

lovastatin 2 Quantity Limitation - 30 tablets per 30 days on 10 and 20mg; 60 tablets per 30 days on 40mg

LOVAZA 3 Quantity Limitation - 120 capsules per 30 days

niacor 1

NIASPAN 3 Quantity Limitation - 60 tablets per 30 days

pravastatin sodium 2 Quantity Limitation - 60 tablets per 30 days on 40mg; 30 tablets per 30 days on 80mg, 10mg, 20mg

prevalite 2

SIMCOR 3 Quantity Limitation - 60 tablets per 30 days

simvastatin 1 Quantity Limitation - 30 tablets per 30 days

TRICOR 3 Quantity Limitation - 30 tablets per 30 days

VYTORIN 4 Quantity Limitation - 30 tablets per 30 days

ZETIA 4 Quantity Limitation - 30 tablets per 30 days

Renin-angiotensin-aldosterone System Inhibitors ATACAND 3 Quantity Limitation - 30 tablets per

30 days

ATACAND HCT 3 Quantity Limitation - 30 tablets per 30 days

benazepril hcl 1 benazepril hcl/hydrochlorothiazide 1

captopril 1 captopril/hydrochlorothiazide 1

39


DIOVAN 3 Step Therapy Protocols Apply; Quantity Limitation - 30 tablets per 30 days

DIOVAN HCT 3 Step Therapy Protocols Apply; Quantity Limitation - 30 tablets per 30 days

enalapril maleate 1 enalapril maleate/hydrochlorothiazide 1

lisinopril 1 lisinopril/hydrochlorothiazide 1 moexipril/hydrochlorothiazide 2 quinapril hcl 2 quinapril/hydrochlorothiazide 2 quinaretic 2

TARKA 3 Quantity Limitation - 30 tablets per 30 days

TEKTURNA 3 Quantity Limitation - 30 tablets per 30 days; Step Therapy Protocols Apply

TEKTURNA HCT 3 Step Therapy Protocols Apply; Quantity Limitation - 30 tablets per 30 days

Vasodilators hydralazine hcl 1

hydralazine hcl 4 Prior Authorization Required; Injectable dosage Formulation

isochron 1 isosorbide dinitrate 1 isosorbide dinitrate er 1 isosorbide mononitrate 1 isosorbide mononitrate er 1 minitran 1 Transdermal Dosage Formulation minoxidil 2 NITRO-DUR 4 Transdermal Dosage Formulation nitroglycerin 1 Transdermal Dosage Formulation

nitroglycerin 4 Prior Authorization Required; Injectable dosage Formulation

nitroglycerin transdermal 1 Transdermal Dosage Formulation NITROLINGUAL PUMPSPRAY 4

CENTRAL NERVOUS SYSTEM AGENTS Amphetamines, ADHD amphetamine salt combo 2 Quantity Limitation - 90 tablets per

40

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS 30 days

amphetamine salts combo 2 Quantity Limitation - 90 tablets per 30 days

dextroamphetamine sulfate 2 Quantity Limitation - 180 tablets per 30 days

dextroamphetamine sulfatecr 2 Quantity Limitation - 120 capsules per 30 days

dextrostat 2 Quantity Limitation - 180 tablets per 30 days

Non-amphetamines, ADHD dexmethylphenidate hcl 2 Quantity Limitation - 90 tablets per

30 days

METADATE CD 4 Quantity Limitation - 60 capsules per 30 days

METADATE CD 4 Quantity Limitation - 180 capsules per 30 days - 10mg capsules

metadate er 1 Quantity Limitation - 90 capsules per 30 days

methylin 1 Quantity Limitation - 90 tablets per 30 days

methylin er 1 Quantity Limitation - 90 tablets per 30 days

methylphenidate hcl 1 Quantity Limitation - 90 tablets per 30 days

methylphenidate hcl er 1 Quantity Limitation - 90 tablets per 30 days

STRATTERA 3 Quantity Limitation - 60 capsules per 30 days

Non-amphetamines, Other

PROVIGIL 3 Quantity Limitation - 60 tablets per 30 days

RILUTEK 4 Prior Authorization Required

XYREM 4

Prior Authorization Required; This prescription may be available only at certain pharmacies. For more information call Member Services at 1-800-546-5677, 24 hours a day, seven days a week. TTY/TDD users should call 1-866-706-4757.

DENTAL AND ORAL AGENTS Dental and Oral Agents APHTHASOL 4 APHTHASOL chlorhexadine gluconateoral 2 CHLORHEXADINE

41

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS rinse GLUCONATEORAL RINSE chlorhexidine gluconate 2 CHLORHEXIDINE GLUCONATE periogard 2 PERIOGARD pilocarpine hcl 2 PILOCARPINE HCL

pilocarpine hydrochloride 2 PILOCARPINE HYDROCHLORIDE

triamcinolone in orabase 2 TRIAMCINOLONE IN ORABASE

DERMATOLOGICAL AGENTS Dermatological Agents 8-MOP 3 Prior Authorization Required

ALDARA 4 Quantity Limitation; Prior Authorization Required; Topical Dosage Formulation

ammonium lactate 2 Topical Dosage Formulation clotrimazole/betamethasone dipropionate

2 Topical Dosage Formulation

colocort 2 CORTIFOAM 4

DOVONEX 4 Quantity Limitation; Topical Dosage Formulation

EFUDEX 4 Prior Authorization Required; Topical Dosage Formulation

ELIDEL 3


erythromycin/benzoyl peroxide 1 fluorouracil 2 Topical Dosage Formulation hydrocortisone 2 laclotion 2 Topical Dosage Formulation lidocaine 2 Topical Dosage Formulation

LIDODERM 4 Quantity Limitation - 90 patches per 30 days; Transdermal Dosage Formulation

ORACEA 4 OXSORALEN ULTRA 4 Prior Authorization Required podofilox 2 Topical Dosage Formulation proctocream-hc 2 proctosol hc 2 proctozone-hc 2

PROTOPIC 4 Prior Authorization Required; Quantity Limitation - 30 grams per prescription; Topical Dosage

42


REGRANEX 5


SANTYL 4 Quantity Limitation -30 grams per prescription; Topical Dosage Formulation

selenium sulfide 2 Topical Dosage Formulation

SOLARAZE 4


TAZORAC 4 Quantity Limitation; Topical Dosage Formulation

u-cort 1 Topical Dosage Formulation

ENZYME REPLACEMENTS/ MODIFIERS Enzyme Replacements/ Modifiers

ADAGEN 5 Prior Authorization Required; Injectable dosage Formulation

ALDURAZYME 5 Prior Authorization Required; Injectable dosage Formulation

BUPHENYL 4

CEREDASE 5 Prior Authorization Required; Injectable dosage Formulation

CEREZYME 5 Prior Authorization Required; Injectable dosage Formulation

CREON 5 3 CREON 10 3 CREON 20 3

ELAPRASE 5 Prior Authorization Required; Injectable dosage Formulation

FABRAZYME 5 Prior Authorization Required; Injectable dosage Formulation

levocarnitine 2

MYOZYME 5 Prior Authorization Required; Injectable dosage Formulation

NAGLAZYME 5 Prior Authorization Required; Injectable dosage Formulation

ORFADIN 5 Prior Authorization Required PALCAPS 10 4 PALCAPS 20 4 PANCREASE MT 10 4

43

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS PANCREASE MT 16 4 PANCREASE MT 20 4 PANCREASE MT 4 4 PANCRELIPASE 4 PANCRELIPASE MST-16 4 SUCRAID 4 VIOKASE 4 VIOKASE 16 4 VIOKASE 8 4 ZAVESCA 4

GASTROINTESTINAL AGENTS Antispasmodics, Gastrointestinal atropine sulfate 1 Prior Authorization Required;

Injectable dosage Formulation CANTIL 4 dicyclomine hcl 1 glycopyrrolate 2 methscopolamine bromide 2 propantheline bromide 2 Gastrointestinal Agents, Other colyte 2 constulose 2 diphenoxylate/atropine 1 enulose 2 GASTROCROM 4 HELIDAC 4 lactulose 2 lofene 1 lonox 1 MOTOFEN 4 NULYTELY 4 peg 3350/electrolytes 2 polyethylene glycol 3350 2 trilyte 2 URSO 250 4 URSO FORTE 4 ursodiol 2 Histamine2 (H2) Blocking Agents cimetidine 2 cimetidine hcl 2 famotidine 1

famotidine 4 Prior Authorization Required; Injectable dosage Formulation

44

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS nizatidine 2 ranitidine hcl 1

ranitidine hcl 4 Prior Authorization Required; Injectable dosage Formulation

Irritable Bowel Syndrome Agents

LOTRONEX 2 Quantity Limitation - 60 tablets per 30 days

Protectants misoprostol 2 sucralfate 1 Proton Pump Inhibitors

NEXIUM 3

Step Therapy Protocols Apply; Quantity Limitation - 30 capsules per 30 days

NEXIUM I.V. 4 Prior Authorization Required; Injectable dosage Formulation

omeprazole 2 Quantity Limitation - 60 capsules per 30 days

pantoprazole 2 Quantity Limitation 30 tablets per 30 days

GENITOURINARY AGENTS Antispasmodics, Urinary bethanechol chloride 2

DETROL 3 Quantity Limitation - 60 tablets per 30 days

DETROL LA 3 Quantity Limitation - 30 capsules per 30 days

ENABLEX 3 Quantity Limitation - 30 tablets per 30 days

flavoxate hcl 1 oxybutynin chloride 1

oxybutynin chloride er 2

Quantity Limitation - 90 tablets per 30 days on 10mg;180 tablets per 30 days on 5mg; 60 tablets per 30 days on 15mg

VESICARE 3 Quantity Limitation - 30 tablets per 30 days

Benign Prostatic Hypertrophy Agents AVODART 3 Quantity Limitation - 30 capsules

per 30 days

finasteride 2 Quantity Limitation - 30 tablets per 30 days

FLOMAX 3 Quantity Limitation - 60 capsules

45

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS per 30 days

UROXATRAL 4 Quantity Limitation - 30 tablets per 30 days

Genitourinary Agents, Other sodium chloride 0.9% 2 THIOLA 3 Phosphate Binders calcium acetate 2 FOSRENOL 4 PHOSLO 3

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (Adrenal)

Glucocorticoids-Mineralocorticoids ala-cort 2 Topical Dosage Formulation alclometasone dipropionate 1 amcinonide 2 Topical Dosage Formulation augmented betamethasone dipropionate 2 Topical Dosage Formulation

betamethasone dipropionate 1 Topical Dosage Formulation betamethasone valerate 1 Topical Dosage Formulation beta-val 1 Topical Dosage Formulation CAPEX 4 Topical Dosage Formulation clobetasol propionate 1 Topical Dosage Formulation clobetasol propionate e 1 Topical Dosage Formulation clobetasol propionate emollient 1 Topical Dosage Formulation cormax 1 Topical Dosage Formulation del-beta 1 Topical Dosage Formulation DERMA-SMOOTHE/FS BODY OIL 4 Topical Dosage Formulation

DERMA-SMOOTHE/FS SCALP OIL

4 Topical Dosage Formulation

desonide 2 Topical Dosage Formulation desoximetasone 2 Topical Dosage Formulation diflorasone diacetate 2 Topical Dosage Formulation fludrocortisone acetate 1 fluocinolone acetonide 1 Topical Dosage Formulation fluocinonide 1 Topical Dosage Formulation fluocinonide emollient base 1 Topical Dosage Formulation fluocinonide-e 1 Topical Dosage Formulation fluticasone propionate 2 Topical Dosage Formulation halobetasol propionate 1 Topical Dosage Formulation HALOG 4 Topical Dosage Formulation

46

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS hydrocortisone 2 Topical Dosage Formulation hydrocortisone butyrate 2 Topical Dosage Formulation hydrocortisone in absorbase 2 Topical Dosage Formulation hydrocortisone valerate 2 Topical Dosage Formulation isovate 1 Topical Dosage Formulation lokara 2 Topical Dosage Formulation mometasone furoate 2 Topical Dosage Formulation OLUX 4 Topical Dosage Formulation prednicarbate 2 Topical Dosage Formulation procto-pak 2 Topical Dosage Formulation texacort 2 Topical Dosage Formulation triamcinolone acetonide 2 Topical Dosage Formulation triamcinolone acetonide in absorbase 2 Topical Dosage Formulation

triderm 2 Topical Dosage Formulation

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin acetate 2

desmopressin acetate 4 Prior Authorization Required; Injectable dosage Formulation

GENOTROPIN 5 Prior Authorization Required; Injectable dosage Formulation

GENOTROPIN MINIQUICK 4 Prior Authorization Required; Injectable dosage Formulation

HUMATROPE 5 Prior Authorization Required; Injectable dosage Formulation

HUMATROPE COMBO PACK 5 Prior Authorization Required; Injectable dosage Formulation

minirin 2

NORDITROPIN CARTRIDGE 5 Prior Authorization Required; Injectable dosage Formulation

NORDITROPIN NORDIFLEX PEN


NUTROPIN 5 Prior Authorization Required; Injectable dosage Formulation

NUTROPIN AQ 5 Prior Authorization Required; Injectable dosage Formulation

NUTROPIN AQ PEN 5 Prior Authorization Required; Injectable dosage Formulation

SAIZEN 5 Prior Authorization Required; Injectable dosage Formulation

47


SAIZEN CLICK.EASY 5 Prior Authorization Required; Injectable dosage Formulation

SEROSTIM 5 Prior Authorization Required; Injectable dosage Formulation

STIMATE 4

ZORBTIVE 5 Prior Authorization Required; Injectable dosage Formulation

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/MODIFIERS)

Anabolic Steroids ANADROL-50 4 oxandrolone 2 Androgens

ANDRODERM 4 Transdermal Dosage Formulation; Quantity Limitation 30 patches per 30 days

ANDROGEL 4 Quantity Limitation - 300 grams per 30 days; Topical Dosage Formulation

ANDROGEL PUMP 4 Quantity Limitation - 300 per 30 days

ANDROID 4 danazol 3 STRIANT 4 Prior Authorization Required TESTIM 3 Topical Dosage Formulation

testosterone cypionate 4 Prior Authorization Required; Injectable dosage Formulation

testosterone enanthate 4 Prior Authorization Required; Injectable dosage Formulation

TESTRED 4 Estrogens ACTIVELLA 4 ALORA 4 Transdermal Dosage Formulation aranelle 2 aviane 1 balziva 1 CENESTIN 4 CLIMARA 4 COMBIPATCH 4 cryselle-28 2 enpresse-28 2 ESTRACE 4 Vaginal Dosage Formulation

48

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ESTRADERM 4 Transdermal Dosage Formulation estradiol 1 estradiol 1 Transdermal Dosage Formulation ESTRASORB 4

ESTRING 4 Vaginal Dosage Formulation; Quantity Limitation

estropipate 1 FEMHRT 1/5 4 FEMHRT LOW DOSE 4 gynodiol 1 junel 1.5/30 2 junel 1/20 2 junel fe 1.5/30 2 junel fe 1/20 2 kelnor 1/35 2 leena 2 lessina-28 2 levora 0.15/30-28 2 low-ogestrel 2 lutera 1 menest 4 microgestin 1.5/30 2 microgestin 1/20 2 microgestin fe 2 microgestin fe 1.5/30 2 mononessa 2 necon 0.5/35-28 2 necon 1/35-28 2 necon 1/50-28 2 necon 10/11-28 2 necon 7/7/7 1 nortrel 0.5/35 (28) 2 nortrel 1/35 (21) 2 nortrel 1/35 (28) 2 nortrel 7/7/7 1 NUVARING 4 Vaginal Dosage Formulation ogestrel 2 ORTHO EVRA 4 Transdermal Dosage Formulation ortho-est 1 portia-28 2 PREFEST 4 PREMARIN 3 PREMARIN W/APPLICATOR 3 Vaginal Dosage Formulation PREMPHASE 3

49

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS PREMPRO 3 previfem 2 quasense 1 sprintec 28 2 sronyx 1 tri-legest fe 1 trinessa 1 tri-previfem 2 tri-sprintec 1 trivora-28 2 VAGIFEM 4 Vaginal Dosage Formulation VIVELLE-DOT 4 Transdermal Dosage Formulation zovia 1/35e 2 zovia 1/50e 2 Progestins camila 2 CRINONE 4 Vaginal Dosage Formulation errin 2 jolivette 2 medroxyprogesterone acetate 1

medroxyprogesterone acetate 4 Prior Authorization Required; Injectable dosage Formulation

MEGACE ES 4 Prior Authorization Required megestrol acetate 2 Prior Authorization Required nora-be 2 norethindrone acetate 2 PLAN B 4 PROCHIEVE 4 Vaginal Dosage Formulation PROMETRIUM 4 Selective Estrogen Receptor Modifying Agents

EVISTA 3 Quantity Limitation - 30 tablets per 30 days

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) CYTOMEL 4 levothroid 1 levothyroxine sodium 1 SYNTHROID 3 THYROLAR-1 4 THYROLAR-1/2 4 THYROLAR-1/4 4

50

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS THYROLAR-2 4 THYROLAR-3 4 unithroid 1

HORMONAL AGENTS, SUPPRESSANT (ADRENAL) Hormonal Agents, Suppressant (Adrenal) LYSODREN 2

HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)

Hormonal Agents, Suppressant (Parathyroid) SENSIPAR 4 Prior Authorization Required 30mg

SENSIPAR 5 Prior Authorization Required 60mg and 90 mg

HORMONAL AGENTS, SUPPRESSANT (PITUITARY) Hormonal Agents, Suppressant (Pituitary) cabergoline 2

DEGARELIX 5

Prior Authorization Required Injectable dosage Formulary; Quantity Limitation 1 injection per 30 days

leuprolide acetate 1 Prior Authorization Required; Injectable dosage Formulation

octreotide acetate 5 Prior Authorization Required; Injectable dosage Formulation

SANDOSTATIN LAR DEPOT 5 Prior Authorization Required; Injectable dosage Formulation

SOMAVERT 5 Prior Authorization Required; Injectable dosage Formulation

SYNAREL 5 Prior Authorization Required

VANTAS 3 Prior Authorization Required; Injectable dosage Formulation

HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/MODIFIERS)

Antiandrogens bicalutamide 2 Quantity Limitation - 30 tablets per

30 days

CASODEX 3 Quantity Limitation - 30 tablets per 30 days

flutamide 1 NILANDRON 4

51


HORMONAL AGENTS, SUPPRESSANTS (THYROID) Antithyroid Agents methimazole 2 propylthiouracil 2

IMMUNOLOGICAL AGENTS Immune Suppressants AZASAN 4 azathioprine 2 CELLCEPT 4 Prior Authorization Required

CELLCEPT INTRAVENOUS 4 Prior Authorization Required; Injectable dosage Formulation

cyclosporine 2 Prior Authorization Required

cyclosporine 4 Prior Authorization Required; Injectable dosage Formulation

CYCLOSPORINE MODIFIED 1 Prior Authorization Required

ENBREL 5

Prior Authorization Required - Quantity Limitaton - 50mg per week; Injectable dosage Formulation

ENBREL SURECLICK 5

Prior Authorization Required - Quantity Limitaton - 50mg per week; Injectable dosage Formulation

gengraf 2 Prior Authorization Required

HUMIRA 5 Prior Authorization Required - Quantity Limitation; Injectable dosage Formulation

HUMIRA PEN 5 Prior Authorization Required - Quantity Limitation; Injectable dosage Formulation

methotrexate 2

methotrexate sodium 4 Prior Authorization Required; Injectable dosage Formulation

MYFORTIC 4 Prior Authorization Required; Injectable dosage Formulation

NEORAL 3 Prior Authorization Required

ORENCIA 5 Prior Authorization Required; Injectable dosage Formulation

ORTHOCLONE OKT3 5 Prior Authorization Required; Injectable dosage Formulation

PROGRAF 4 Prior Authorization Required PROGRAF 4 Prior Authorization Required;

52


RAPAMUNE 4 Prior Authorization Required

REMICADE 5 Prior Authorization Required; Injectable dosage Formulation

SANDIMMUNE 4 Prior Authorization Required; Oral Solution Formulation

SANDIMMUNE 3 Prior Authorization Required; Oral Capsule Formulation

SANDIMMUNE 3 Prior Authorization Required; Injectable dosage Formulation

SIMPONI 5 Prior Authorization Required; Injectable dosage Formulation

SIMULECT 5 Prior Authorization Required; Injectable dosage Formulation

ZENAPAX 5 Prior Authorization Required; Injectable dosage Formulation

Immunizing Agents, Passive carimune nanofiltered 5 Prior Authorization Required;


flebogamma 5 Prior Authorization Required; Injectable dosage Formulation

gamastan s/d 5 Prior Authorization Required; Injectable dosage Formulation

GAMMAGARD LIQUID 5 Prior Authorization Required; Injectable dosage Formulation

GAMUNEX 5 Prior Authorization Required; Injectable dosage Formulation

iveegam en 5 Prior Authorization Required; Injectable dosage Formulation

octagam 5 Prior Authorization Required; Injectable dosage Formulation

PANGLOBULIN 5 Prior Authorization Required; Injectable dosage Formulation

panglobulin nf 5 Prior Authorization Required; Injectable dosage Formulation

polygam s/d 4 Prior Authorization Required; Injectable dosage Formulation

VIVAGLOBIN 5 Prior Authorization Required; Injectable dosage Formulation

Immunomodulators

ACTIMMUNE 5 Prior Authorization Required; Injectable dosage Formulation

ALFERON N 5 Prior Authorization Required; Injectable dosage Formulation

53


AVONEX 5

Prior Authorization Required; Quantity Limitation - 1 kit per 28 days; Injectable dosage Formulation

BETASERON 5 Prior Authorization Required; Injectable dosage Formulation

COPAXONE 5

Prior Authorization Required - Quantity Limitation - 1 kit per 30 days; Injectable dosage Formulation

INFERGEN 5 Prior Authorization Required; Injectable dosage Formulation

INTRON-A 5 Prior Authorization Required; Injectable dosage Formulation

INTRON-A W/DILUENT 5 Prior Authorization Required; Injectable dosage Formulation

KINERET 5 Prior Authorization Required; Injectable dosage Formulation

leflunomide 2

MYOBLOC 4 Prior Authorization Required; Injectable dosage Formulation

PEGASYS 5 Prior Authorization Required; Injectable dosage Formulation; Quantity Limitation

PEG-INTRON 5 Prior Authorization Required; Injectable dosage Formulation; Quantity Limitation

PEG-INTRON REDIPEN 5 Prior Authorization Required; Injectable dosage Formulation; Quantity Limitation

PEG-INTRON REDIPEN PAK 4 5 Prior Authorization Required; Injectable dosage Formulation; Quantity Limitation

REBIF 5

Prior Authorization Required - Quantity Limitation - 12 injections per 30 days; Injectable dosage Formulation

REBIF TITRATION PACK 5

Prior Authorization Required - Quantity Limitation - 12 injections per 30 days; Injectable dosage Formulation

RIDAURA 4

TYSABRI 5 Prior Authorization Required; This prescription may be available only at certain pharmacies. For more

54

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS information call Member Services at 1-800-546-5677, 24 hours a day, seven days a week. TTY/TDD users should call 1-866-706-4757.

Vaccines ACTHIB 4 ADACEL 4 ATTENUVAX 4 BOOSTRIX 4 COMVAX 4 DAPTACEL 4 decavac 4 DIPTHERIA/TETANUS TOXOIDPEDIATRIC 4

ENGERIX-B 4

GARDASIL 4 Prior Authorization Required; Injectable dosage Formulation

HAVRIX 4 HIBTITER 4 IMOVAX RABIES (H.D.C.V.) 4 INFANRIX 4 IPOL INACTIVATED IPV 4 IXIARO 4 JE-VAX 4 MENACTRA 4 MENOMUNE-A/C/Y/W-135 4 MERUVAX II W/DILUENT 10 DOSE

3

M-M-R II W/DILUENT 10 DOS 4 PEDIARIX 4 pedvax hib 4 PROQUAD 4 RABAVERT 4 RECOMBIVAX HB 4 ROTATEQ 4 TETANUS TOXOID ADSORBED

3

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT 4

TRIHIBIT 4 TRIPEDIA 4 TWINRIX 4 TYPHIM VI 4 VAQTA 4

55

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS VARIVAX 4 VIVOTIF BERNA 4 YF-VAX 4 Injectable dosage Formulation

ZOSTAVAX 4 Prior Authorization Required; Injectable dosage Formulation

INFLAMMATORY BOWEL DISEASE AGENTS Salicylates ASACOL 3 balsalazide disodium 1 CANASA 4 COLAZAL 4 DIPENTUM 4 mesalamine 2 PENTASA 4 Sulfonamides sulfasalazine 1 sulfazine 1 sulfazine ec 1

METABOLIC BONE DISEASE AGENTS Metabolic Bone Disease Agents

ACTONEL 4

Quantity Limitation - 30 per 30 days on 5mg;5 per 30 days on 35mg, and 30mg; 2 per 28 days on 75mg; Step Therapy Protocols Apply

ACTONEL WITH CALCIUM 4 Quantity Limitation - 28 tablets per 30 days

alendronate sodium 1 Quantity Limitation - 30 per 30 days on 5mg and 10mg;5 per 30 days on 40mg and 70mg

BONIVA 4

Prior Authorization Required - 3mg/3ml only; Quantity Limitation - 1 per 30 days on 3mg/3ml; Injectable dosage Formulation; Step Therapy Protocols Apply

BONIVA 4

Prior Authorization Required - 3mg/3ml only; Quantity Limitation - 1 per 30 days on 3mg/3ml; Injectable dosage Formulation; Step Therapy Protocols Apply

calcitonin/salmon 2 CALCITRIOL 4 Prior Authorization Required;

56


calcitriol 2

calcitriol 2 Prior Authorization Required; Oral Solution Formulation

etidronate disodium 1

FORTEO 5 Prior Authorization Required; Injectable dosage Formulation

FORTICAL 4

pamidronate disodium 5 Prior Authorization Required; Injectable dosage Formulation

ZEMPLAR 3 Prior Authorization Required

OPHTHALMIC AGENTS Ophthalmic Agents, Other ak-con 1 bac/poly/neomy/hc 1 BLEPHAMIDE 4 BLEPHAMIDE S.O.P. 4 COSOPT 4 dexasporin 2 dorzolamide/timolol 1 LACRISERT 4 naphazoline hcl 1 neo/poly/bac/hc 2 neomycin/polymyxin/dexamethasone 2

neomycin/polymyxin/hydrocortisone

1

parcaine 2 poly-dex 2 POLY-PRED 4 PRED-G 4 PRED-G S.O.P. 4 proparacaine hcl 2 RESTASIS 4 Prior Authorization Required sulfacetamide sodium/prednisolone sodium phosphate

2

TOBRADEX 4 Ophthalmic Anti-allergy Agents ALAMAST 4 Step Therapy Protocols Apply ALOCRIL 4 Step Therapy Protocols Apply ALOMIDE 4 Step Therapy Protocols Apply cromolyn sodium 2 Step Therapy Protocols Apply

57

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ketotifen fumarate 1 OPTIVAR 4 Step Therapy Protocols Apply Ophthalmic Antiglaucoma Agents acetazolamide 2 ALPHAGAN P 4 AZOPT 4 betaxolol hcl 2 BETIMOL 4 BETOPTIC-S 4 brimonidine tartrate 2 carteolol hcl 2 dipivefrin hcl 2 IOPIDINE 4 levobunolol hcl 2 metipranolol 1 mydral 2 PHOSPHOLINE IODIDE 4 PILOPINE HS 4 timolol maleate 1 timolol maleate ophthalmic gel forming

1 tropicacyl 2 tropicamide 2 TRUSOPT 4 Ophthalmic Anti-inflammatories ACULAR 4 ACULAR LS 4 ACULAR PF 4 ALREX 4 dexamethasone sodium phosphate

1 diclofenac sodium 1 FLAREX 4 fluorometholone 1 fluor-op 1 flurbiprofen sodium 2 FML FORTE 4 FML S.O.P. 4 LOTEMAX 4 MAXIDEX 4 NEVANAC 4 PRED MILD 4 prednisolone acetate 2 prednisolone sodium phosphate 2

58

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS VEXOL 4 Ophthalmic Prostaglandins and Prostamide Analogs LUMIGAN 4 Quantity Limitation - 7.5ml per 30

days

TRAVATAN 4 Quantity Limitation - 5ml per 30 days

TRAVATAN Z 4 Quantity Limitation - 5ml per 30 days

XALATAN 3 Quantity Limitation - 5ml per 30 days

OTIC AGENTS Otic Agents acetic acid 2 acetic acid/hydrocortisone 2 borofair 1 CIPRO HC 3 CIPRODEX 4 COLY-MYCIN-S 4 cortomycin 1 DERMOTIC 3 neomycin/polymyxin/hc 1 neomycin/polymyxin/hydrocortisone 1

oticin hc 1

RESPIRATORY TRACT AGENTS Antihistamines ASTELIN 4 Quantity Limitation - 1 inhaler per

30 days clemastine fumarate 1 cyproheptadine hcl 1 dexchlorpheniramine maleate 1

fexofenadine hcl 2 Quantity Limitation - 30 tablets per 30 days on 180mg; 60 tablets per 30 days on 30mg and 60mg

hydroxyzine hcl 1

hydroxyzine hcl 4 Prior Authorization Required; Injectable dosage Formulation

palgic 2 Anti-inflammatories, Inhaled Corticosteroids

AEROBID 4 Quantity Limitation - 3 inhalers per 30 days

AEROBID-M 4 Quantity Limitation - 3 inhalers per

59


ASMANEX 120 METERED DOSES

4 Quantity Limitation - 1 inhaler per 30 days

ASMANEX 14 METERED DOSES 4 Quantity Limitation - 3 inhalers per

30 days ASMANEX 30 METERED DOSES 4 Quantity Limitation - 1 inhaler per

30 days ASMANEX 60 METERED DOSES 4 Quantity Limitation - 1 inhaler per

30 days

AZMACORT 4 Quantity Limitation - 2 inhalers per 30 days

BECONASE AQ 4 Quantity Limitation - 1 inhaler per 30 days

FLOVENT HFA 3 Quantity Limitation - 2 inhalers per 30 days

flunisolide 1 Quantity Limitation - 1 inhaler per 30 days

fluticasone propionate 2 Quantity Limitation - 1 inhaler per 30 days

NASACORT AQ 4 Quantity Limitation - 2 inhalers per 30 days

NASONEX 4 Quantity Limitation - 2 inhalers per 30 days

PULMICORT FLEXHALER 3 Quantity Limitation - 2 inhalers per 30 days

QVAR 4 Quantity Limitation - 3 inhalers per 30 days

RHINOCORT AQUA 3 Quantity Limitation - 2 inhalers per 30 days

VERAMYST 3 Antileukotrienes

ACCOLATE 3 Quantity Limitation - 60 tablets per 30 days

SINGULAIR 4

Step Therapy Protocols Apply; Quantity Limitation - 30 tablets per 30 days

ZYFLO CR 4 Quantity Limitation - 120 tablets per 30 days

Bronchodilators, Anticholinergic ATROVENT HFA 4 Quantity Limitation - 2 inhalers per

30 days ipratropium bromide 2

ipratropium bromide 2 Quantity Limitation - 30ml per 30 days

60


SPIRIVA HANDIHALER 4 Quantity Limitation - 1 handihaler per 30 days

Bronchodilators, Phosphodiesterase 2 Inhibitors (Xanthines) aminophylline 2 theochron 1 theophylline cr 1 theophylline er 1 theophylline td 1 Bronchodilators, Sympathomimetic ADVAIR DISKUS 3 Quantity Limitation - 1 inhaler per

30 days

ADVAIR HFA 3 Quantity Limitation - 1 inhaler per 30 days

albuterol sulfate 1 albuterol sulfate er 1

ALUPENT 3 Quantity Limitation - 2 inhalers per 30 days

COMBIVENT 3 Quantity Limitation - 2 inhalers per 30 days

epinephrine hcl 2 Prior Authorization Required; Injectable dosage Formulation

EPIPEN 2-PAK 4 Quantity Limitation; Injectable dosage Formulation

EPIPEN-JR 2-PAK 4 Quantity Limitation; Injectable dosage Formulation

FORADIL AEROLIZER 4 Quantity Limitation - 1 inhaler per 30 days

MAXAIR AUTOHALER 4 Quantity Limitation - 2 inhalers per 30 days

metaproterenol sulfate 2

PROAIR HFA 4 Quantity Limitation - 2 inhalers per 30 days

PROVENTIL HFA 4 Quantity Limitation - 2 inhalers per 30 days

SEREVENT DISKUS 3 Quantity Limitation - 1 inhaler per 30 days

SYMBICORT 3 terbutaline sulfate 1

terbutaline sulfate 4 Prior Authorization Required; Injectable dosage Formulation

TWINJECT 4 Prior Authorization Required; Injectable dosage Formulation

Mast Cell Stabilizers INTAL INHALER 3 Quantity Limitation - 2 inhalers per

61


Pulmonary Antihypertensives ADCIRCA 5 Prior Authorization Required REVATIO 5 Prior Authorization Required Respiratory Tract Agents, Other ARALAST 5 Prior Authorization Required;

Injectable dosage Formulation PROLASTIN 5 promethazine vc 2

VENTAVIS 5 Prior Authorization Required; Injectable dosage Formulation

XOLAIR 5 Prior Authorization Required; Injectable dosage Formulation

ZEMAIRA 4 Prior Authorization Required; Injectable dosage Formulation

SEDATIVES/ HYPNOTICS Sedatives/Hypnotics

ROZEREM 4 Step Therapy Protocols Apply; Quantity Limitation - 30 tablets per 30 days

zolpidem tartrate 2 Quantity Limitation - 30 tablets per 30 days

SKELETAL MUSCLE RELAXANTS Skeletal Muscle Relaxants carisoprodol 2 Quantity Limitation carisoprodol/aspirin 2 Quantity Limitation carisoprodol/aspirin/codeine 2 Quantity Limitation chlorzoxazone 2 Quantity Limitation cyclobenzaprine hcl 1 methocarbamol 2

orphenadrine citrate 4 Prior Authorization Required; Injectable dosage Formulation

orphenadrine citrate er 2 orphenadrine compound 2 orphenadrine compound ds 1 orphenadrine/asa/caff 2

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES

Electrolytes/Minerals AMINOSYN 4 Prior Authorization Required;

62


AMINOSYN 7%/ELECTROLYTES


aminosyn 8.5%/electrolytes 4 Prior Authorization Required; Injectable dosage Formulation

AMINOSYN II 4 Prior Authorization Required; Injectable dosage Formulation

AMINOSYN II 3.5%/DEXTROSE5% 4 Prior Authorization Required;

Injectable dosage Formulation AMINOSYN II 3.5%/DEXTROSE25% 4 Prior Authorization Required;

Injectable dosage Formulation AMINOSYN II 4.25/DEXTROSE10%


AMINOSYN II 4.25/DEXTROSE20% 4 Prior Authorization Required;

Injectable dosage Formulation AMINOSYN II 4.25/DEXTROSE25%


AMINOSYN II 5/DEXTROSE 25 4 Prior Authorization Required; Injectable dosage Formulation

aminosyn ii 8.5%/electrolytes 4 Prior Authorization Required; Injectable dosage Formulation

AMINOSYN II M 3.5%/DEXTROSE 5% 4 Prior Authorization Required;

Injectable dosage Formulation AMINOSYN II M 4.25/DEXTROSE 10%


AMINOSYN M 4 Prior Authorization Required; Injectable dosage Formulation

AMINOSYN-HBC 4 Prior Authorization Required; Injectable dosage Formulation

aminosyn-hf 4 Prior Authorization Required; Injectable dosage Formulation

AMINOSYN-PF 4 Prior Authorization Required; Injectable dosage Formulation

AMINOSYN-PF 7% 4 Prior Authorization Required; Injectable dosage Formulation

DEXTROSE 10%/NACL 0.45% 4 Prior Authorization Required; Injectable dosage Formulation

dextrose 5%/electrolyte #48 viaflex 4 Prior Authorization Required;

Injectable dosage Formulation dextrose 5%/electrolyte #75 viaflex 4 Prior Authorization Required;


dextrose 10% 4 Prior Authorization Required; Injectable dosage Formulation

dextrose 10%/nacl 0.2% 4 Prior Authorization Required;

63


dextrose 2.5%/nacl 0.45% 4 Prior Authorization Required; Injectable dosage Formulation

dextrose 2.5%/sodium chloride 0.45% 4 Prior Authorization Required;


dextrose 5% 4 Prior Authorization Required; Injectable dosage Formulation

dextrose 5%/lactated ringer's 4 Prior Authorization Required; Injectable dosage Formulation

dextrose 5%/nacl 0.2% 4 Prior Authorization Required; Injectable dosage Formulation





DEXTROSE 5%/POTASSIUM CHLORIDE 0.075%


dextrose 5%/potassium chloride 0.15% 4 Prior Authorization Required;

Injectable dosage Formulation dextrose 5%/sodium chloride 0.2%


dextrose 5%/sodium chloride 0.33% 4 Prior Authorization Required;

Injectable dosage Formulation dextrose 5%/sodium chloride 0.45%


dextrose 5%/sodium chloride 0.9% 4 Prior Authorization Required;

Injectable dosage Formulation ed k+10 1

freamine iii 4 Prior Authorization Required; Injectable dosage Formulation

FREAMINE III 3% 4 Prior Authorization Required; Injectable dosage Formulation

intralipid 4 Prior Authorization Required; Injectable dosage Formulation

intralipid 20% 4 Prior Authorization Required; Injectable dosage Formulation

kaon-cl-10 1

kcl 0.075%/d5w/nacl 0.2% 4 Prior Authorization Required; Injectable dosage Formulation

kcl 0.075%/d5w/nacl 0.45% 4 Prior Authorization Required;

64


KCL 0.15%/D10W/NACL 0.2% 4 Prior Authorization Required; Injectable dosage Formulation

kcl 0.15%/d5w/ nacl 0.3% 4 Prior Authorization Required; Injectable dosage Formulation

KCL 0.15%/D5W/LR 4 Prior Authorization Required; Injectable dosage Formulation





KCL 0.3%/D5W/LR 4 Prior Authorization Required; Injectable dosage Formulation

KCL 0.3%/D5W/LR IV LAC RING 4 Prior Authorization Required;




KCL 0.3%/D5W/NACL 0.9% 4 Prior Authorization Required; Injectable dosage Formulation

klor-con 10 1 klor-con 8 1 klor-con m10 1 klor-con m20 1 klotrix 1 lactated ringer's dextrose 5% viaflex 4 Prior Authorization Required;


lactated ringer's viaflex 4 Prior Authorization Required; Injectable dosage Formulation

MAGNESIUM SULFATE 4 Prior Authorization Required; Injectable dosage Formulation

MICRO-K 3

potassium chloride 4 Prior Authorization Required; Injectable dosage Formulation

potassium chloride 0.075%/d5w/nacl 0.225% 4 Prior Authorization Required;


potassium chloride 0.15% 4 Prior Authorization Required; Injectable dosage Formulation

potassium chloride 0.15%/d5w 4 Prior Authorization Required;

65


POTASSIUM CHLORIDE 0.15%/NACL 0.45% VIAFLEX


potassium chloride 0.15%d5w/nacl 0.33% 4 Prior Authorization Required;

Injectable dosage Formulation potassium chloride 0.15%d5w/nacl 0.45% viaflex 4 Prior Authorization Required;

Injectable dosage Formulation potassium chloride 0.22%d5w/nacl 0.45% 4 Prior Authorization Required;


potassium chloride 0.224%/d5w 4 Prior Authorization Required; Injectable dosage Formulation

potassium chloride 0.224%/d5w/nacl 0.45%


POTASSIUM CHLORIDE 0.224%D5W/NACL 0.33% 4 Prior Authorization Required;


potassium chloride 0.3%/d5w 4 Prior Authorization Required; Injectable dosage Formulation

potassium chloride 0.3%/nacl 0.9%/viaflex 4 Prior Authorization Required;

Injectable dosage Formulation potassium chloride cr 1 potassium chloride er 1 potassium chloride sr 1

sodium bicarbonate 4 Prior Authorization Required; Injectable dosage Formulation

sodium chloride 4 Prior Authorization Required; Injectable dosage Formulation

sodium chloride 0.45% viaflex 4 Prior Authorization Required; Injectable dosage Formulation

tpn electrolytes ftv 4 Prior Authorization Required; Injectable dosage Formulation

TRAVASOL 2.75%/DEXTROSE 10%


TRAVASOL 2.75%/DEXTROSE 5% 4 Prior Authorization Required;


travasol 3.5%/electrolytes 4 Prior Authorization Required; Injectable dosage Formulation

TRAVASOL 4.25%/DEXTROSE 10% 4 Prior Authorization Required;

Injectable dosage Formulation TRAVASOL 5.5%/ELECTROLYTES


TROPHAMINE 4 Prior Authorization Required; Injectable dosage Formulation

Vitamins vitamin/mineral, misc 1

66


ENHANCED COVERAGE DRUGS (Coverage only available for Citrus Part D Plus

Members) alprazolam 2 Coverage available for Citrus

Part D Plus Members. Quantity Limitation 120 tablets per 30 days ; This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

CIALIS 4 Coverage available for Citrus Part D Plus Members. Quantity Limitation 6 tablets per 30 days; This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

diazepam 2 Coverage available for Citrus Part D Plus Members. Quantity Limitation 60 tablets per 30 days ; This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs

67

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

folic acid 1mg 2 Coverage available for Citrus Part D Plus Members. This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

lorazepam 2 Coverage available for Citrus Part D Plus Members. Quantity Limitation 120 tablets per 30 days ; This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

VIAGRA 4 Coverage available for Citrus Part D Plus Members. Quantity Limitation 6 tablets per 30 days; This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not

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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

69

Index of Drugs Therapeutic Classes and Categories Therapeutic Categories are listed in Bold Therapeutic Classes are also listed in Bold 8-MOP....................................................... 41 ABELCET................................................. 19 ABILIFY................................................... 26 ABILIFY DISCMELT.............................. 26 Abortive.................................................... 21 ACCOLATE ............................................. 59 acebutolol hcl ............................................ 35 ACETADOTE........................................... 18 acetaminophen/codeine........................... 7, 9 acetaminophen/codeine #2.......................... 7 acetaminophen/codeine #3.......................... 7 acetaminophen/codeine #4.......................... 7 acetazolamide............................................ 57 acetic acid ................................................. 58 acetic acid/hydrocortisone ........................ 58 ACTHIB.................................................... 54 acticin........................................................ 25 ACTIMMUNE.......................................... 52 ACTIVELLA ............................................ 47 ACTONEL................................................ 55 ACTONEL WITH CALCIUM ................. 55 ACTOPLUS MET .................................... 29 ACTOS...................................................... 29 ACULAR .................................................. 57 ACULAR LS............................................. 57 ACULAR PF............................................. 57 acyclovir.................................................... 28 ADACEL .................................................. 54 ADAGEN.................................................. 42 ADCIRCA................................................. 61 ADVAIR DISKUS.................................... 60 ADVAIR HFA.......................................... 60 AEROBID................................................. 58 AEROBID-M............................................ 58 afeditab cr ................................................. 36 AFINITOR................................................ 24 AGGRENOX ............................................ 34 ak-con........................................................ 56 ak-poly-bac................................................ 10

ak-tob ........................................................ 10 ala-cort ...................................................... 45 ALAMAST ............................................... 56 albuterol sulfate ........................................ 60 albuterol sulfate er .................................... 60 alclometasone dipropionate...................... 45 ALCOHOL SWABS................................. 30 ALDARA.................................................. 41 ALDURAZYME....................................... 42 alendronate sodium................................... 55 ALFERON N ............................................ 52 ALINIA..................................................... 25 Alkylating Agents .................................... 22 allopurinol................................................. 20 ALOCRIL ................................................. 56 ALOMIDE ................................................ 56 ALORA..................................................... 47 Alpha-adrenergic Agonists..................... 35 Alpha-adrenergic Blocking Agents ....... 35 ALPHAGAN P ......................................... 57 ALREX ..................................................... 57 ALUPENT ................................................ 60 amantadine hcl.......................................... 25 amcinonide ................................................ 45 a-methapred .............................................. 21 amiloride hcl ............................................. 37 amiloride/hydrochlorothiazide ................. 37 Aminoglycosides...................................... 10 aminophylline............................................ 60 AMINOSYN ....................................... 61, 62 AMINOSYN 7%/ELECTROLYTES ....... 62 aminosyn 8.5%/electrolytes ...................... 62 AMINOSYN II ......................................... 62 AMINOSYN II 3.5%/DEXTROSE25%... 62 AMINOSYN II 3.5%/DEXTROSE5%..... 62 AMINOSYN II 4.25/DEXTROSE10% .... 62 AMINOSYN II 4.25/DEXTROSE20% .... 62 AMINOSYN II 4.25/DEXTROSE25% .... 62 AMINOSYN II 5/DEXTROSE 25 ........... 62

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aminosyn ii 8.5%/electrolytes ................... 62 AMINOSYN II M 3.5%/DEXTROSE 5%62 AMINOSYN II M 4.25/DEXTROSE 10%

............................................................... 62 AMINOSYN M ........................................ 62 AMINOSYN-HBC ................................... 62 aminosyn-hf ............................................... 62 AMINOSYN-PF ....................................... 62 AMINOSYN-PF 7%................................. 62 amiodarone hcl ......................................... 35 amitriptyline hcl ........................................ 18 amlodipine besylate................................... 36 amlodipine besylate/benazepril

hydrochloride ........................................ 36 ammonium lactate..................................... 41 amoclan..................................................... 12 amoxapine................................................. 17 amoxicillin................................................. 12 amoxicillin/clavulanate potassium............ 12 amoxil........................................................ 12 amphetamine salt combo........................... 39 amphetamine salts combo......................... 40 Amphetamines, ADHD ........................... 39 amphotericin b .......................................... 19 ampicillin .................................................. 12 AMPICILLIN SODIUM........................... 12 ampicillin-sulbactam................................. 12 Anabolic Steroids .................................... 47 ANADROL-50.......................................... 47 anagrelide hydrochloride.......................... 34 ANALGESICS ........................................... 7 ANCOBON............................................... 19 ANDRODERM......................................... 47 ANDROGEL............................................. 47 ANDROGEL PUMP................................. 47 Androgens ................................................ 47 ANDROID ................................................ 47 ANESTHETICS ...................................... 10 ANTABUSE ............................................. 18 Anthelmintics........................................... 24 Antiandrogens ......................................... 50 Antiangiogenic Agents ............................ 23 Antiarrhythmics ...................................... 35 ANTIBACTERIALS ............................... 10 Antibacterials, Other.............................. 10 Anticoagulants ......................................... 33

ANTICONVULSANTS .......................... 14 Anticonvulsants, Other........................... 14 Anti-cytomegalovirus (CMV) Agents .... 27 ANTIDEMENTIA AGENTS ................. 16 Antidementia Agents, Other .................. 16 ANTIDEPRESSANTS ............................ 17 Antidepressants, Other........................... 17 Antidiabetic Agents ................................. 29 Antidotes .................................................. 18 ANTIDOTES, DETERRENTS, AND

TOXICOLOGIC AGENTS ................ 18 Antiemetics .............................................. 19 ANTIEMETICS ...................................... 19 Antiestrogens/Modifiers ......................... 23 Antifungals............................................... 19 ANTIFUNGALS ..................................... 19 Antigout Agents ....................................... 20 ANTIGOUT AGENTS ........................... 20 Antihepatitis Agents................................ 28 Antiherpetic Agents ................................ 28 Antihistamines......................................... 58 Anti-HIV Agents, Non-nucleoside Reverse

Transcriptase Inhibitors ..................... 28 Anti-HIV Agents, Nucleoside and

Nucleotide Reverse Transcriptase Inhibitors ............................................. 28

Anti-HIV Agents, Other......................... 28 Anti-HIV Agents, Protease Inhibitors ... 29 Anti-inflammatories, Inhaled

Corticosteroids .................................... 58 ANTI-INFLAMMATORY AGENTS ... 21 Anti-influenza Agents ............................. 29 Antileukotrienes ...................................... 59 Antimetabolites........................................ 23 ANTIMIGRAINE AGENTS .................. 21 ANTIMYASTHENIC AGENTS ............ 22 ANTIMYCOBACTERIALS .................. 22 Antimycobacterials, Other..................... 22 ANTINEOPLASTICS ............................ 22 Antineoplastics, Other............................ 23 ANTIPARASITICS ................................ 24 Antiparkinson Agents ............................. 25 ANTIPARKINSON AGENTS ............... 25 Antiprotozoals ......................................... 25 ANTIPSYCHOTICS ............................... 26 Antispasmodics, Gastrointestinal .......... 43

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Antispasmodics, Urinary ........................ 44 Antispasticity Agents .............................. 27 ANTISPASTICITY AGENTS ............... 27 Antithyroid Agents.................................. 51 Antituberculars ....................................... 22 ANTIVIRALS ......................................... 27 ANTIZOL ................................................. 18 ANXIOLYTICS ...................................... 29 Anxiolytics, Other ................................... 29 APHTHASOL........................................... 40 APIDRA.................................................... 30 APLENZIN ............................................... 17 APOKYN.................................................. 25 APTIVUS.................................................. 29 APTIVUS SOLUTION............................. 29 ARALAST................................................ 61 aranelle ..................................................... 47 ARANESP ALBUMIN FREE............ 33, 34 ARANESP ALBUMIN FREE SURE....... 34 ARICEPT.................................................. 16 ARICEPT ODT......................................... 16 ARIMIDEX............................................... 24 ARIXTRA................................................. 33 AROMASIN ............................................. 24 Aromatase Inhibitors, 3rd Generation . 23 ARRANON............................................... 23 ASACOL................................................... 55 ascomp/codeine ........................................... 7 ASMANEX 120 METERED DOSES ...... 59 ASMANEX 14 METERED DOSES ........ 59 ASMANEX 30 METERED DOSES ........ 59 ASMANEX 60 METERED DOSES ........ 59 ASTELIN .................................................. 58 ATACAND............................................... 38 ATACAND HCT...................................... 38 atamet........................................................ 25 atenolol...................................................... 36 atenolol/chlorthalidone ............................. 36 ATRIPLA.................................................. 28 atropine sulfate ......................................... 43 ATROVENT HFA.................................... 59 ATTENUVAX.......................................... 54 Atypicals................................................... 26 augmented betamethasone dipropionate .. 45 AVANDAMET......................................... 29 AVANDARYL ......................................... 29

AVANDIA................................................ 29 AVASTIN ................................................. 24 AVELOX .................................................. 13 AVELOX ABC PACK ............................. 13 aviane........................................................ 47 AVODART............................................... 44 AVONEX.................................................. 53 AZACTAM............................................... 12 AZACTAM IN DEXTROSE.................... 12 AZASAN .................................................. 51 azathioprine .............................................. 51 AZILECT.................................................. 25 azithromycin........................................ 12, 13 AZMACORT ............................................ 59 AZOPT...................................................... 57 bac/poly/neomy/hc .................................... 56 bacitracin .................................................. 10 bacitracin/neomycin/polymyxin ................ 10 bacitracin/polymyxin b.............................. 10 baclofen..................................................... 27 BALACET 325 ........................................... 7 balsalazide disodium................................. 55 balziva....................................................... 47 BANZEL................................................... 14 BARACLUDE .......................................... 28 BECONASE AQ....................................... 59 benazepril hcl ............................................ 38 benazepril hcl/hydrochlorothiazide .......... 38 Benign Prostatic Hypertrophy Agents .. 44 benztropine mesylate................................. 25 BESIVANCE ............................................ 13 Beta-adrenergic Blocking Agents .......... 36 Beta-lactam, Cephalosporins ................. 11 Beta-lactam, Other.................................. 12 Beta-lactam, Penicillins .......................... 12 betamethasone dipropionate..................... 45 betamethasone valerate............................. 45 BETASERON........................................... 53 beta-val...................................................... 45 betaxolol hcl........................................ 36, 57 bethanechol chloride................................. 44 BETIMOL................................................. 57 BETOPTIC-S............................................ 57 bicalutamide.............................................. 50 BILTRICIDE ............................................ 24 Bipolar Agents ......................................... 29

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BIPOLAR AGENTS ............................... 29 bisoprolol fumarate................................... 36 bisoprolol fumarate/hydrochlorothiazide . 36 bleomycin sulfate....................................... 23 BLEPHAMIDE......................................... 56 BLEPHAMIDE S.O.P. ............................. 56 Blood Formation Products ..................... 33 BLOOD GLUCOSE REGULATORS... 29 Blood Glucose Regulators, Misc............ 30 BLOOD PRODUCTS/MODIFIERS/

VOLUME EXPANDERS ................... 33 BONIVA ................................................... 55 BOOSTRIX............................................... 54 borofair ..................................................... 58 brimonidine tartrate.................................. 57 bromocriptine mesylate............................. 25 Bronchodilators, Anticholinergic .......... 59 Bronchodilators, Sympathomimetic...... 60 budeprion sr .............................................. 17 budeprion xl .............................................. 17 bumetanide................................................ 37 BUPHENYL ............................................. 42 buprenorphine hcl....................................... 7 bupropion hcl ............................................ 17 bupropion hcl sr........................................ 17 buspirone hcl............................................. 29 butal/asa/caff/cod........................................ 7 butalbital/apap/caffeine/codeine................. 7 butorphanol tartrate.................................... 7 BYETTA................................................... 29 cabergoline................................................ 50 CADUET .................................................. 38 calcitonin/salmon ...................................... 55 calcitriol .................................................... 56 CALCITRIOL........................................... 55 calcium acetate ......................................... 45 Calcium Channel Blocking Agents ........ 36 Calcium Channel Modifying Agents ..... 14 camila........................................................ 49 CAMPATH ............................................... 24 CANASA .................................................. 55 CANCIDAS .............................................. 20 CANTIL.................................................... 43 CAPASTAT SULFATE ........................... 22 CAPEX...................................................... 45 captopril .................................................... 38

captopril/hydrochlorothiazide .................. 38 carbamazepine .......................................... 15 CARBATROL .......................................... 15 carbidopa/levodopa .................................. 25 carbidopa/levodopa cr .............................. 25 carbidopa/levodopa er .............................. 25 carbidopa/levodopa odt ............................ 25 carbidopa/levodopa sr .............................. 25 CARDIOVASCULAR AGENTS ........... 35 Cardiovascular Agents, Other............... 37 carimune nanofiltered ............................... 52 carisoprodol.............................................. 61 carisoprodol/aspirin ................................. 61 carisoprodol/aspirin/codeine .................... 61 carteolol hcl .............................................. 57 cartia xt..................................................... 35 carvedilol .................................................. 36 CASODEX................................................ 50 CEENU ..................................................... 22 cefaclor...................................................... 11 cefaclor er ................................................. 11 cefadroxil .................................................. 11 CEFAZOLIN SODIUM............................ 11 cefdinir ...................................................... 11 cefoxitin sodium ........................................ 11 cefpodoxime proxetil................................. 11 cefprozil..................................................... 11 ceftriaxone sodium.................................... 12 cefuroxime axetil....................................... 12 CELEBREX................................................ 9 CELESTONE............................................ 21 CELLCEPT............................................... 51 CELLCEPT INTRAVENOUS ................. 51 CELONTIN............................................... 14 CENESTIN ............................................... 47 CENTRAL NERVOUS SYSTEM

AGENTS .............................................. 39 cephalexin ................................................. 12 CEREBYX................................................ 15 CEREDASE.............................................. 42 CEREZYME............................................. 42 chlordiazepoxide ....................................... 17 chlordiazepoxide/amitriptyline ................. 17 chlorhexadine gluconateoral rinse ........... 40 chlorhexidine gluconate............................ 41 chloroquine phosphate.............................. 25

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chlorothiazide............................................ 37 chlorpromazine hcl ................................... 19 chlorpropamide ......................................... 30 chlorthalidone ........................................... 37 chlorzoxazone............................................ 61 cholestyramine .......................................... 38 cholestyramine light .................................. 38 Cholinesterase Inhibitors ....................... 16 ciclopirox .................................................. 20 ciclopirox nail lacquer.............................. 20 ciclopirox olamine..................................... 20 cilostazol ................................................... 34 cimetidine .................................................. 43 cimetidine hcl ............................................ 43 CIPRO HC ................................................ 58 CIPRODEX............................................... 58 ciprofloxacin er ......................................... 13 ciprofloxacin hcl ....................................... 13 citalopram hydrobromide ......................... 17 clarithromycin ........................................... 13 clarithromycin er....................................... 13 clemastine fumarate.................................. 58 CLIMARA ................................................ 47 clindamycin hcl ......................................... 10 clindamycin phosphate.............................. 10 clobetasol propionate................................ 45 clobetasol propionate e............................. 45 clobetasol propionate emollient ................ 45 clomipramine hcl....................................... 18 clonidine hcl .............................................. 35 clotrimazole......................................... 20, 41 clotrimazole/betamethasone dipropionate 41 clozapine ................................................... 26 Coagulants ............................................... 34 co-gesic ....................................................... 7 COGNEX.................................................. 16 COLAZAL................................................ 55 colchicine .................................................. 20 colestipol hcl ............................................. 38 colistimethate sodium................................ 10 colocort ..................................................... 41 COLY-MYCIN-S ..................................... 58 colyte......................................................... 43 COMBIVENT........................................... 60 COMBIVIR............................................... 28 compro ...................................................... 27

COMTAN ................................................. 25 COMVAX................................................. 54 constulose.................................................. 43 Conventional............................................ 27 COPAXONE............................................. 53 COREG CR............................................... 36 cormax....................................................... 45 CORTIFOAM ........................................... 41 cortisone acetate....................................... 21 cortomycin................................................. 58 COSOPT................................................... 56 COUMADIN............................................. 33 CREON 5 ................................................. 42 CREON 10 ................................................ 42 CREON 20 ................................................ 42 CRESTOR................................................. 38 CRINONE................................................. 49 CRIXIVAN ............................................... 29 cromolyn sodium ....................................... 56 cryselle-28 ................................................. 47 CUPRIMINE............................................. 18 cyclobenzaprine hcl................................... 61 cyclophosphamide ..................................... 23 cyclosporine .............................................. 51 CYCLOSPORINE MODIFIED................ 51 CYKLOKAPRON .................................... 34 CYMBALTA ............................................ 17 cyproheptadine hcl .................................... 58 CYTOMEL ............................................... 49 CYTOVENE............................................. 27 danazol ...................................................... 47 dantrolene sodium..................................... 27 DAPSONE ................................................ 22 DAPTACEL.............................................. 54 DARAPRIM ............................................. 25 decavac...................................................... 54 DEGARELIX............................................ 50 del-beta...................................................... 45 demeclocycline hcl .................................... 14 Dental and Oral Agents .......................... 40 DENTAL AND ORAL AGENTS .......... 40 DEPACON................................................ 14 DEPAKOTE........................................ 15, 22 DEPAKOTE ER ....................................... 22 DEPAKOTE SPRINKLES ....................... 15 DEPEN TITRATABS............................... 18

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DERMA-SMOOTHE/FS BODY OIL...... 45 DERMA-SMOOTHE/FS SCALP OIL ..... 45 Dermatological Agents............................ 41 DERMATOLOGICAL AGENTS ......... 41 DERMOTIC.............................................. 58 desipramine hcl......................................... 18 desmopressin acetate ................................ 46 desonide .................................................... 45 desoximetasone ......................................... 45 Deterrents ................................................ 18 DETROL................................................... 44 DETROL LA............................................. 44 dexamethasone.................................... 21, 57 dexamethasone sodium phosphate............ 57 dexasporin................................................. 56 dexchlorpheniramine maleate................... 58 dexmethylphenidate hcl............................. 40 dextroamphetamine sulfate....................... 40 dextroamphetamine sulfatecr.................... 40 DEXTROSE 10%/NACL 0.45% ............. 62 dextrose 5%/electrolyte #48 viaflex ......... 62 dextrose 5%/electrolyte #75 viaflex ......... 62 dextrose 10%............................................. 62 dextrose 10%/nacl 0.2% ........................... 62 dextrose 2.5%/nacl 0.45% ........................ 63 dextrose 2.5%/sodium chloride 0.45% ..... 63 dextrose 5%............................................... 63 dextrose 5%/lactated ringer's ................... 63 dextrose 5%/nacl 0.2% ............................. 63 dextrose 5%/nacl 0.225% ......................... 63 dextrose 5%/nacl 0.33% ........................... 63 dextrose 5%/nacl 0.45% ........................... 63 dextrose 5%/nacl 0.9% ............................. 63 DEXTROSE 5%/POTASSIUM

CHLORIDE 0.075% ............................. 63 dextrose 5%/potassium chloride 0.15%.... 63 dextrose 5%/sodium chloride 0.2% .......... 63 dextrose 5%/sodium chloride 0.33% ........ 63 dextrose 5%/sodium chloride 0.45% ........ 63 dextrose 5%/sodium chloride 0.9% .......... 63 dextrostat................................................... 40 DIABETIC SUPPLIES, MISC ................. 30 diclofenac potassium................................... 9 diclofenac sodium ................................. 9, 57 diclofenac sodium dr ................................... 9 diclofenac sodium ec ................................... 9

diclofenac sodium er ................................... 9 diclofenac sodium xr................................... 9 dicloxacillin sodium .................................. 12 dicyclomine hcl ......................................... 43 didanosine ................................................. 28 diflorasone diacetate................................. 45 diflunisal...................................................... 9 digitek........................................................ 37 digoxin....................................................... 37 DILANTIN................................................ 15 DILANTIN INFATABS ........................... 15 dilt-cd ........................................................ 35 diltiazem cd ............................................... 35 diltiazem hcl .............................................. 35 diltiazem hcl er.......................................... 35 dilt-xr......................................................... 35 DIOVAN................................................... 39 DIOVAN HCT.......................................... 39 DIPENTUM.............................................. 55 diphenhydramine hcl................................. 19 diphenoxylate/atropine.............................. 43 dipivefrin hcl ............................................. 57 DIPTHERIA/TETANUS

TOXOIDPEDIATRIC .......................... 54 dipyridamole ............................................. 34 disopyramide phosphate ........................... 35 disopyramide phosphate er ....................... 35 Diuretics ................................................... 37 dolorex forte................................................ 7 dorzolamide/timolol .................................. 56 DOVONEX............................................... 41 doxazosin mesylate.................................... 35 doxepin hcl ................................................ 18 doxy-caps .................................................. 14 doxycycline hyclate ................................... 14 DOXYCYCLINE HYCLATE .................. 14 doxycycline monohydrate.......................... 14 DROXIA ................................................... 23 Dyslipidemics ........................................... 37 e.e.s. 200.................................................... 13 e.e.s. 400.................................................... 13 econazole nitrate....................................... 20 ed k+10 ..................................................... 63 EFFEXOR XR .......................................... 17 EFFIENT................................................... 34 EFUDEX................................................... 41

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ELAPRASE .............................................. 42 Electrolytes/Minerals .............................. 61 ELIDEL..................................................... 41 ELITEK..................................................... 23 EMCYT..................................................... 22 EMEND .................................................... 19 EMSAM.................................................... 17 EMTRIVA ................................................ 28 ENABLEX................................................ 44 enalapril maleate ...................................... 39 enalapril maleate/hydrochlorothiazide..... 39 ENBREL................................................... 51 ENBREL SURECLICK............................ 51 endocet ........................................................ 7 ENGERIX-B ............................................. 54 enpresse-28 ............................................... 47 ENTOCORT EC ....................................... 21 enulose ...................................................... 43 Enzyme Replacements/ Modifiers ......... 42 ENZYME REPLACEMENTS/

MODIFIERS........................................ 42 epinephrine hcl.......................................... 60 EPIPEN 2-PAK......................................... 60 EPIPEN-JR 2-PAK ................................... 60 epitol.......................................................... 15 EPIVIR...................................................... 28 EPIVIR HBV ............................................ 28 EPOGEN................................................... 34 EPZICOM................................................. 28 ERAXIS .................................................... 20 ergoloid mesylates..................................... 16 errin........................................................... 49 eryderm ..................................................... 13 ery-tab ....................................................... 13 ERYTHROCIN......................................... 13 ERYTHROCIN LACTOBIONATE......... 13 erythrocin stearate.................................... 13 erythromycin ................................. 11, 13, 41 erythromycin base ..................................... 13 erythromycin ethylsuccinate ..................... 13 ERYTHROMYCIN LACTOBIONATE .. 13 erythromycin/benzoyl peroxide ................. 41 erythromycin/sulfisoxazole........................ 11 ESTRACE................................................. 47 ESTRADERM .......................................... 48 estradiol .................................................... 48

ESTRASORB ........................................... 48 ESTRING.................................................. 48 Estrogens .................................................. 47 estropipate................................................. 48 ethambutol hcl........................................... 22 ethosuximide.............................................. 14 etidronate disodium .................................. 56 EVISTA .................................................... 49 EXELDERM............................................. 20 EXELON................................................... 16 EXFORGE ................................................ 36 EXJADE.................................................... 18 FABRAZYME.......................................... 42 famciclovir ................................................ 28 famotidine.................................................. 43 FANSIDAR............................................... 25 FARESTON.............................................. 23 FAZACLO ................................................ 26 FELBATOL.............................................. 15 FEMARA.................................................. 24 FEMHRT 1/5 ............................................ 48 FEMHRT LOW DOSE............................. 48 fenofibrate................................................. 38 fenoprofen calcium...................................... 9 fentanyl........................................................ 7 fexofenadine hcl ........................................ 58 finasteride.................................................. 44 FLAREX ................................................... 57 flavoxate hcl.............................................. 44 flebogamma............................................... 52 flecainide acetate ...................................... 35 FLOMAX.................................................. 44 FLOVENT HFA ....................................... 59 fluconazole ................................................ 20 fludrocortisone acetate ............................. 45 flunisolide.................................................. 59 fluocinolone acetonide .............................. 45 fluocinonide............................................... 45 fluocinonide emollient base ...................... 45 fluocinonide-e............................................ 45 fluorometholone ........................................ 57 fluor-op...................................................... 57 fluorouracil ............................................... 41 fluoxetine hcl............................................. 17 fluphenazine decanoate............................. 27 fluphenazine hcl ........................................ 27

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flurbiprofen ........................................... 9, 57 flurbiprofen sodium................................... 57 flutamide.................................................... 50 fluticasone propionate ........................ 45, 59 fluvoxamine maleate................................. 17 FML FORTE............................................. 57 FML S.O.P. ............................................... 57 FORADIL AEROLIZER .......................... 60 FORTEO ................................................... 56 FORTICAL............................................... 56 foscarnet sodium ....................................... 28 FOSCAVIR............................................... 28 fosphenytoin sodium.................................. 15 FOSRENOL.............................................. 45 FRAGMIN ................................................ 33 freamine iii ................................................ 63 FREAMINE III 3%................................... 63 furosemide................................................. 37 FUZEON................................................... 28 gabapentin................................................. 15 GABITRIL................................................ 15 galantamine............................................... 16 galantamine er .......................................... 16 gamastan s/d ............................................. 52 Gamma-aminobutyric Acid (GABA)

Augmenting Agents ............................. 14 GAMMAGARD LIQUID......................... 52 GAMUNEX .............................................. 52 ganciclovir ................................................ 28 GANTRISIN PEDIATRIC ....................... 13 GARDASIL .............................................. 54 GASTROCROM....................................... 43 GASTROINTESTINAL AGENTS ........ 43 Gastrointestinal Agents, Other.............. 43 gemfibrozil ................................................ 38 gengraf ...................................................... 51 GENITOURINARY AGENTS .............. 44 Genitourinary Agents, Other................. 45 genoptic..................................................... 10 GENOTROPIN ......................................... 46 GENOTROPIN MINIQUICK .................. 46 gentak........................................................ 10 gentamicin sulfate..................................... 10 gentasol ..................................................... 10 GEODON.................................................. 26 GLEEVEC ................................................ 24

glimepiride ................................................ 30 glipizide ..................................................... 30 glipizide er................................................. 30 glipizide xl................................................. 30 glipizide/metformin hcl ............................. 30 GLUCAGEN HYPOKIT .......................... 30 GLUCAGON EMERGENCY KIT........... 30 Glucocorticoids .................................. 21, 45 Glutamate Pathway Modifiers ............... 16 Glutamate Reducing Agents .................. 15 glyburide ................................................... 30 glyburide micronized................................. 30 glyburide/metformin hcl............................ 30 Glycemic Agents ...................................... 30 glycopyrrolate........................................... 43 glycron ...................................................... 30 GLYSET ................................................... 30 granisetron hcl .......................................... 19 granisol ..................................................... 19 GRIFULVIN V ......................................... 20 griseofulvin microsize ............................... 20 guanabenz acetate..................................... 35 guanfacine hcl ........................................... 35 GUANIDINE HCL................................... 22 gynodiol..................................................... 48 halobetasol propionate ............................. 45 HALOG..................................................... 45 haloperidol................................................ 27 haloperidol decanoate............................... 27 haloperidol lactate.................................... 27 HAVRIX ................................................... 54 HELIDAC ................................................. 43 heparin sodium.......................................... 33 HEPARIN SODIUM ................................ 33 HEPARIN SODIUM DCU....................... 33 HEPARIN SODIUM/NACL 0.45% ......... 33 heparin sodium/nacl 0.9% ........................ 33 HEPSERA................................................. 28 HERCEPTIN............................................. 24 HEXALEN................................................ 22 HIBTITER ................................................ 54 Histamine2 (H2) Blocking Agents ......... 43 Hormonal Agents,

Stimulant/Replacement/Modifying (Pituitary)............................................. 46

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Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) .............................................. 49

Hormonal Agents, Suppressant (Adrenal)............................................................... 50

HORMONAL AGENTS, SUPPRESSANT (ADRENAL)........... 50

Hormonal Agents, Suppressant (Parathyroid) ....................................... 50

HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) 50

Hormonal Agents, Suppressant (Pituitary)............................................. 50

HORMONAL AGENTS, SUPPRESSANT (PITUITARY) ........ 50

HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/MODIFIERS) ............. 50

HUMALOG ........................................ 30, 31 HUMALOG MIX 50/50 ..................... 30, 31 HUMALOG MIX 50/50 PEN................... 31 HUMALOG MIX 75/25 ........................... 31 HUMALOG MIX 75/25 PEN................... 31 HUMALOG PEN...................................... 31 HUMATROPE.......................................... 46 HUMATROPE COMBO PACK .............. 46 HUMIRA .................................................. 51 HUMIRA PEN.......................................... 51 HUMULIN 50/50...................................... 31 HUMULIN 70/30...................................... 31 HUMULIN 70/30 PEN ............................. 31 HUMULIN N............................................ 31 HUMULIN N U-100 PEN ........................ 31 HUMULIN R ............................................ 31 hydralazine hcl .......................................... 39 hydrochlorothiazide .................................. 37 hydrocodone bitartrate/acetaminophen...... 7 hydrocodone/acetaminophen ...................... 8 hydrocodone/acetaminophen-hs ................. 8 hydrocodone/ibuprofen ............................... 8 hydrocortisone .............................. 21, 41, 46 hydrocortisone butyrate............................ 46 hydrocortisone in absorbase ..................... 46 hydrocortisone valerate ............................ 46 hydromorphone hcl ..................................... 8 hydroxychloroquine sulfate....................... 25

hydroxyurea .............................................. 23 hydroxyzine hcl ......................................... 58 hydroxyzine pamoate................................. 19 ibuprofen ..................................................... 9 imipramine hcl .......................................... 18 IMITREX.................................................. 21 IMITREX STATDOSE REFILL.............. 21 Immune Suppressants ............................ 51 Immunizing Agents, Passive .................. 52 IMMUNOLOGICAL AGENTS ............ 51 Immunomodulators ................................ 52 IMOVAX RABIES (H.D.C.V.)................ 54 indapamide................................................ 37 indomethacin............................................... 9 indomethacin er........................................... 9 INFANRIX................................................ 54 INFERGEN............................................... 53 INFLAMMATORY BOWEL DISEASE

AGENTS .............................................. 55 INNOHEP ................................................. 33 INSPRA .................................................... 37 Insulins ..................................................... 30 INTAL INHALER .................................... 60 INTELENCE............................................. 28 intralipid.................................................... 63 intralipid 20% ........................................... 63 INTRON-A ............................................... 53 INTRON-A W/DILUENT ........................ 53 INVANZ ................................................... 12 INVEGA ................................................... 26 INVERSINE.............................................. 37 INVIRASE................................................ 29 IOPIDINE ................................................. 57 IPOL INACTIVATED IPV...................... 54 ipratropium bromide ................................. 59 IRESSA..................................................... 24 Irritable Bowel Syndrome Agents ......... 44 ISENTRESS.............................................. 28 isochron..................................................... 39 isonarif ...................................................... 22 isoniazid .................................................... 22 isosorbide dinitrate................................... 39 isosorbide dinitrate er............................... 39 isosorbide mononitrate ............................. 39 isosorbide mononitrate er ......................... 39 isovate ....................................................... 46

78

isradipine .................................................. 36 itraconazole............................................... 20 iveegam en................................................. 52 IXIARO..................................................... 54 jantoven..................................................... 33 JANUMET................................................ 30 JANUVIA ................................................. 30 JE-VAX..................................................... 54 jolivette...................................................... 49 junel 1.5/30................................................ 48 junel 1/20................................................... 48 junel fe 1.5/30............................................ 48 junel fe 1/20............................................... 48 KADIAN..................................................... 8 KALETRA................................................ 29 kaon-cl-10 ................................................. 63 KAYEXALATE........................................ 18 kcl 0.075%/d5w/nacl 0.2%........................ 63 kcl 0.075%/d5w/nacl 0.45% ..................... 63 KCL 0.15%/D10W/NACL 0.2% .............. 64 kcl 0.15%/d5w/ nacl 0.3%......................... 64 KCL 0.15%/D5W/LR ............................... 64 kcl 0.15%/d5w/nacl 0.2%.......................... 64 kcl 0.15%/d5w/nacl 0.225% ..................... 64 kcl 0.15%/d5w/nacl 0.45%........................ 64 kcl 0.224%/d5w/nacl 0.2%........................ 64 KCL 0.3%/D5W/LR ................................. 64 KCL 0.3%/D5W/LR IV LAC RING ........ 64 kcl 0.3%/d5w/nacl 0.2%............................ 64 kcl 0.3%/d5w/nacl 0.45%.......................... 64 KCL 0.3%/D5W/NACL 0.9% .................. 64 kelnor 1/35 ................................................ 48 KEMADRIN ............................................. 25 KEPPRA ................................................... 14 KEPPRA XR............................................. 14 ketoconazole.............................................. 20 ketorolac tromethamine .............................. 9 ketot ifen fumarate..................................... 57 KINERET.................................................. 53 KIONEX ................................................... 18 klor-con 10 ................................................ 64 klor-con 8 .................................................. 64 klor-con m10 ............................................. 64 klor-con m20 ............................................. 64 klotrix ........................................................ 64 kuric .......................................................... 20

labetalol hcl............................................... 36 laclotion .................................................... 41 LACRISERT............................................. 56 lactated ringer's dextrose 5% viaflex........ 64 lactated ringer's viaflex............................. 64 lactulose .................................................... 43 LAMICTAL.............................................. 15 LAMICTAL STARTER/NOT TAKING

CARBAMAZEPINE............................. 15 LAMICTAL STARTER/TAKING

CARBAMAZEPINE/NOT TAKING VALPROATE....................................... 15

LAMICTAL STARTER/TAKING VALPROATE....................................... 15

LAMICTAL XR ....................................... 15 LAMISIL .................................................. 20 lamotrigine chewable dispersible ............. 15 LANOXIN ................................................ 37 LANTUS ................................................... 31 LANTUS SOLOSTAR ............................. 31 leena .......................................................... 48 leflunomide................................................ 53 lessina-28 .................................................. 48 LEUCOVORIN CALCIUM ..................... 19 LEUKERAN ............................................. 22 leuprolide acetate...................................... 50 LEVATOL................................................ 36 LEVEMIR................................................. 31 LEVEMIR FLEXPEN .............................. 31 levobunolol hcl .......................................... 57 levocarnitine.............................................. 42 levora 0.15/30-28 ...................................... 48 levorphanol tartrate.................................... 8 levothroid .................................................. 49 levothyroxine sodium ................................ 49 LEXAPRO ................................................ 17 LEXIVA.................................................... 29 lidocaine.............................................. 10, 41 lidocaine hcl .............................................. 10 lidocaine hcl jelly ...................................... 10 lidocaine/prilocaine .................................. 10 LIDODERM.............................................. 41 lidomar viscous ......................................... 10 lindane....................................................... 25 LIPITOR ................................................... 38 lisinopril.................................................... 39

79

lisinopril/hydrochlorothiazide .................. 39 lithium carbonate...................................... 29 lithium carbonate er.................................. 29 lithium citrate............................................ 29 Local Anesthetics..................................... 10 LODOSYN................................................ 25 lofene......................................................... 43 lofibra........................................................ 38 lokara ........................................................ 46 lonox.......................................................... 43 LOPROX................................................... 20 LOPROX SHAMPOO.............................. 20 LOTEMAX ............................................... 57 LOTRONEX ............................................. 44 lovastatin................................................... 38 LOVAZA .................................................. 38 LOVENOX ............................................... 33 low-ogestrel............................................... 48 loxapine succinate..................................... 27 LUMIGAN................................................ 58 lutera ......................................................... 48 LYRICA.................................................... 14 LYSODREN ............................................. 50 Macrolides................................................ 12 MAGNESIUM SULFATE ....................... 64 MALARONE............................................ 25 maprotiline hcl .......................................... 17 margesic-h................................................... 8 MARPLAN ............................................... 17 Mast Cell Stabilizers ............................... 60 MATULANE............................................ 22 MAXAIR AUTOHALER......................... 60 MAXIDEX................................................ 57 MAXIPIME .............................................. 12 mebendazole.............................................. 25 meclizine hcl.............................................. 19 meclofenamate sodium................................ 9 medroxyprogesterone acetate................... 49 mefloquine hcl ........................................... 25 MEGACE ES ............................................ 49 megestrol acetate...................................... 49 meloxicam ................................................... 9 MENACTRA ............................................ 54 menest........................................................ 48 MENOMUNE-A/C/Y/W-135................... 54 meperidine hcl............................................. 8

meperitab .................................................... 8 meprobamate............................................. 29 MEPRON.................................................. 25 mercaptopurine ......................................... 23 MERREM ................................................. 12 MERUVAX II W/DILUENT 10 DOSE... 54 mesalamine................................................ 55 MESNEX .................................................. 19 MESTINON.............................................. 22 MESTINON TIMESPAN ......................... 22 Metabolic Bone Disease Agents ............. 55 METABOLIC BONE DISEASE

AGENTS .............................................. 55 METADATE CD...................................... 40 metadate er................................................ 40 metaproterenol sulfate.............................. 60 metformin hcl ............................................ 30 metformin hcl er ........................................ 30 methadone hcl ............................................. 8 METHADONE HCL .................................. 8 methadose.................................................... 8 methazolamide .......................................... 37 methenamine hippurate............................. 11 METHERGINE......................................... 34 methimazole .............................................. 51 methocarbamol.......................................... 61 methotrexate.............................................. 51 methotrexate sodium ................................. 51 methscopolamine bromide ........................ 43 methyclothiazide........................................ 37 methyldopa................................................ 35 methyldopa/hydrochlorothiazide .............. 35 methyldopate hcl ....................................... 35 methylin..................................................... 40 methylin er................................................. 40 methylphenidate hcl .................................. 40 methylphenidate hcl er .............................. 40 methylprednisolone ................................... 21 methylprednisolone acetate....................... 21 methylprednisolone sodiumsuccinate ....... 21 metipranolol .............................................. 57 metoclopramide hcl................................... 19 metolazone ................................................ 37 metoprolol succinate er............................. 36 metoprolol tartrate.................................... 36 metoprolol/hydrochlorothiazide ............... 36

80

metronidazole............................................ 11 metronidazole vaginal............................... 11 mexiletine hcl ............................................ 35 miconazole 3 ............................................. 20 microgestin 1.5/30..................................... 48 microgestin 1/20........................................ 48 microgestin fe............................................ 48 microgestin fe 1.5/30................................. 48 MICRO-K ................................................. 64 midodrine hcl ............................................ 35 migergot .................................................... 21 minirin ....................................................... 46 minitran..................................................... 39 minocycline hcl ......................................... 14 minoxidil.................................................... 39 MINTEZOL.............................................. 25 MIRAPEX................................................. 25 mirtazapine................................................ 17 misoprostol................................................ 44 mitoxantrone hcl ....................................... 23 M-M-R II W/DILUENT 10 DOS ............. 54 MOBAN.................................................... 27 moexipril/hydrochlorothiazide.................. 39 Molecular Target Inhibitors .................. 24 mometasone furoate.................................. 46 Monoamine Oxidase Inhibitors ............. 17 Monoclonal Antibodies........................... 24 mononessa................................................. 48 morphine sulfate.......................................... 8 morphine sulfate er ..................................... 8 MOTOFEN ............................................... 43 mupirocin .................................................. 11 MYCOBUTIN .......................................... 22 mydral ....................................................... 57 MYFORTIC .............................................. 51 MYLOTARG............................................ 24 MYOBLOC............................................... 53 MYOZYME.............................................. 42 myrac......................................................... 14 MYTELASE ............................................. 22 NA............................................................... 7 nabumetone................................................. 9 nadolol ...................................................... 36 nadolol/bendroflumethiazide .................... 36 NAFCILLIN SODIUM............................. 12 NAFTIN .................................................... 20

NAFTIN-MP............................................. 20 NAGLAZYME ......................................... 42 nalbuphine hcl............................................. 8 NAMENDA .............................................. 16 NAMENDA TITRATION PAK............... 16 naphazoline hcl ......................................... 56 naproxen...................................................... 9 naproxen dr................................................. 9 naproxen sodium......................................... 9 NARDIL.................................................... 17 narvox.......................................................... 8 NASACORT AQ ...................................... 59 NASONEX................................................ 59 NATACYN ............................................... 20 NAVANE.................................................. 27 necon 0.5/35-28......................................... 48 necon 1/35-28............................................ 48 necon 1/50-28............................................ 48 necon 10/11-28.......................................... 48 necon 7/7/7 ................................................ 48 nefazodone hcl........................................... 17 neo/poly/bac/hc ......................................... 56 NEO-FRADIN .......................................... 10 neomycin sulfate........................................ 10 neomycin/bacitracin zn/polymyx............... 11 neomycin/bacitracin/polymyxin ................ 11 neomycin/polymyxin/dexamethasone........ 56 neomycin/polymyxin/gramicidin ............... 11 neomycin/polymyxin/hc ............................. 58 neomycin/polymyxin/hydrocortisone .. 56, 58 NEORAL .................................................. 51 NEULASTA.............................................. 34 NEUMEGA............................................... 34 NEUPOGEN ............................................. 34 NEURONTIN ........................................... 15 NEUTREXIN............................................ 25 NEVANAC ............................................... 57 NEXAVAR ............................................... 24 NEXIUM................................................... 44 NEXIUM I.V. ........................................... 44 niacor ........................................................ 38 NIASPAN ................................................. 38 nicardipine hcl .......................................... 36 NICOTROL NS ........................................ 19 nifediac cc ................................................. 36 nifedical xl................................................. 36

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nifedipine................................................... 36 nifedipine er .............................................. 36 NILANDRON........................................... 50 nimodipine................................................. 37 NITRO-DUR............................................. 39 nitrofurantoin macrocrystalline ................ 11 nitrofurantoin monohydrate...................... 11 nitroglycerin.............................................. 39 nitroglycerin transdermal ......................... 39 NITROLINGUAL PUMPSPRAY............ 39 nizatidine ................................................... 44 Non-amphetamines, ADHD ................... 40 Non-amphetamines, Other ..................... 40 nora-be ...................................................... 49 NORDITROPIN CARTRIDGE................ 46 NORDITROPIN NORDIFLEX PEN ....... 46 norethindrone acetate............................... 49 nortrel 0.5/35 (28)..................................... 48 nortrel 1/35 (21)........................................ 48 nortrel 1/35 (28)........................................ 48 nortrel 7/7/7 .............................................. 48 nortriptyline hcl......................................... 18 NORVIR ................................................... 29 NOVOLIN 70/30 ................................ 31, 32 NOVOLIN 70/30 INNOLET.................... 32 NOVOLIN 70/30 PENFILL ..................... 32 NOVOLIN N............................................. 32 NOVOLIN N INNOLET .......................... 32 NOVOLIN N U-100 PENFILL ................ 32 NOVOLIN R............................................. 32 NOVOLIN R INNOLET .......................... 32 NOVOLIN R U-100 PENFILL ................ 32 NOVOLOG............................................... 32 NOVOLOG MIX 70/30 ............................ 32 NOVOLOG MIX 70/30 PENFILL........... 32 NOVOLOG MIX 70/30 PREFILLED

FLEXPEN ............................................. 32 NOVOLOG PENFILL.............................. 32 NUCYNTA ................................................. 8 NULYTELY ............................................. 43 NUTROPIN .............................................. 46 NUTROPIN AQ........................................ 46 NUTROPIN AQ PEN ............................... 46 NUVARING ............................................. 48 nyamyc ...................................................... 20 nystatin...................................................... 20

nystatin/triamcinolone .............................. 20 nystop ........................................................ 20 octagam..................................................... 52 octreotide acetate...................................... 50 ocusulf-10.................................................. 13 ofloxacin.................................................... 13 ogestrel...................................................... 48 OLUX........................................................ 46 omeprazole ................................................ 44 ondansetron hcl......................................... 19 ondansetron odt......................................... 19 ONTAK..................................................... 23 OPHTHALMIC AGENTS ..................... 56 Ophthalmic Agents, Other..................... 56 Ophthalmic Anti-allergy Agents ............ 56 Ophthalmic Antiglaucoma Agents ........ 57 Ophthalmic Anti-inflammatories .......... 57 Opioid Analgesics...................................... 7 OPTIVAR ................................................. 57 ORACEA .................................................. 41 ORAP ........................................................ 27 ORENCIA................................................. 51 ORFADIN................................................. 42 orphenadrine citrate ................................. 61 orphenadrine citrate er ............................. 61 orphenadrine compound ........................... 61 orphenadrine compound ds....................... 61 orphenadrine/asa/caff ............................... 61 ORTHO EVRA......................................... 48 ORTHOCLONE OKT3 ............................ 51 ortho-est .................................................... 48 Otic Agents............................................... 58 OTIC AGENTS ....................................... 58 oticin hc..................................................... 58 OVIDE ...................................................... 25 oxandrolone .............................................. 47 oxaprozin..................................................... 9 oxcarbazepine ........................................... 15 OXSORALEN ULTRA ............................ 41 oxybutynin chloride................................... 44 oxybutynin chloride er .............................. 44 oxycodone hcl.............................................. 8 oxycodone/acetaminophen.......................... 8 oxycodone/aspirin ....................................... 8 oxycodone/ibuprofen................................... 8 pacerone.................................................... 35

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PALCAPS 10 ............................................ 42 PALCAPS 20 ............................................ 42 palgic......................................................... 58 pamidronate disodium .............................. 56 PANCREASE MT 10 ............................... 42 PANCREASE MT 16 ............................... 43 PANCREASE MT 20 ............................... 43 PANCREASE MT 4 ................................. 43 PANCRELIPASE ..................................... 43 PANCRELIPASE MST-16....................... 43 panglobulin ............................................... 52 PANGLOBULIN ...................................... 52 panglobulin nf ........................................... 52 PANRETIN............................................... 24 pantoprazole ........................................... 44 Parasympathomimetics .......................... 22 parcaine .................................................... 56 paromomycin sulfate................................. 10 paroxetine hcl............................................ 17 PAXIL CR................................................. 18 PEDIARIX................................................ 54 Pediculicides/Scabicides ......................... 25 pedi-dri...................................................... 20 pedvax hib ................................................. 54 peg 3350/electrolytes ................................ 43 PEGANONE............................................. 16 PEGASYS ................................................. 53 PEG-INTRON........................................... 53 PEG-INTRON REDIPEN......................... 53 PEG-INTRON REDIPEN PAK 4............. 53 penicillin g potassium ............................... 12 PENICILLIN G POTASSIUM IN ISO-

OSMOTIC DEXTROSE....................... 12 PENICILLIN G PROCAINE.................... 12 PENICILLIN G SODIUM........................ 12 penicillin v potassium................................ 12 PENTASA................................................. 55 pentazocine/acetaminophen ........................ 8 pentazocine/naloxone hcl ............................ 8 pentopak.................................................... 34 pentoxifylline er......................................... 35 pentoxil...................................................... 35 periogard................................................... 41 permethrin................................................. 25 perphenazine ....................................... 17, 19 perphenazine/amitriptyline ....................... 17

PHENYTEK.............................................. 16 phenytoin................................................... 16 phenytoin sodium ...................................... 16 phenytoin sodium extended....................... 16 PHOSLO ................................................... 45 Phosphate Binders .................................. 45 PHOSPHOLINE IODIDE ........................ 57 phrenilin w/caffeine/codeine ....................... 8 pilocarpine hcl .......................................... 41 pilocarpine hydrochloride......................... 41 PILOPINE HS........................................... 57 pindolol ..................................................... 36 PIPERACILLIN SODIUM....................... 12 piroxicam .................................................... 9 PLAN B..................................................... 49 Platelet Aggregation Inhibitors ............. 34 PLAVIX.................................................... 35 podofilox.................................................... 41 polycin b .................................................... 11 poly-dex ..................................................... 56 polyethylene glycol 3350........................... 43 polygam s/d ............................................... 52 polymyxin b sulfate/trimethoprim sulfate.. 11 POLY-PRED............................................. 56 portia-28.................................................... 48 potassium chloride .............................. 64, 65 potassium chloride 0.075%/d5w/nacl

0.225% .................................................. 64 potassium chloride 0.15%................... 64, 65 potassium chloride 0.15%/d5w ................. 64 POTASSIUM CHLORIDE 0.15%/NACL

0.45% VIAFLEX .................................. 65 potassium chloride 0.15%d5w/nacl 0.33%65 potassium chloride 0.15%d5w/nacl 0.45%

viaflex.................................................... 65 potassium chloride 0.22%d5w/nacl 0.45%65 potassium chloride 0.224%/d5w ............... 65 potassium chloride 0.224%/d5w/nacl 0.45%

............................................................... 65 POTASSIUM CHLORIDE

0.224%D5W/NACL 0.33% .................. 65 potassium chloride 0.3%/d5w ................... 65 potassium chloride 0.3%/nacl 0.9%/viaflex

............................................................... 65 potassium chloride cr................................ 65 potassium chloride er................................ 65

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potassium chloride sr ................................ 65 PRANDIN................................................. 30 pravastatin sodium.................................... 38 prazosin hcl............................................... 35 PRECOSE................................................. 30 PRED MILD ............................................. 57 PRED-G .................................................... 56 PRED-G S.O.P.......................................... 56 prednicarbate............................................ 46 prednisolone........................................ 21, 57 prednisolone acetate................................. 57 prednisolone sodium phosphate.......... 21, 57 prednisone ................................................. 21 prednisone intensol ................................... 21 PREFEST.................................................. 48 PREMARIN .............................................. 48 PREMARIN W/APPLICATOR ............... 48 PREMPHASE........................................... 48 PREMPRO ................................................ 49 prevalite .................................................... 38 previfem..................................................... 49 PREZISTA................................................ 29 PRIFTIN.................................................... 22 PRIMAQUINE PHOSPHATE ................. 25 primidone .................................................. 15 PRISTIQ.................................................... 18 PROAIR HFA........................................... 60 probenecid........................................... 20, 21 probenecid/colchicine ............................... 21 PROCHIEVE ............................................ 49 prochlorperazine ................................. 19, 27 prochlorperazine edisylate........................ 19 prochlorperazine maleate ......................... 19 PROCRIT.................................................. 34 proctocream-hc ......................................... 41 procto-pak ................................................. 46 proctosol hc............................................... 41 proctozone-hc............................................ 41 Progestins ................................................. 49 PROGLYCEM.......................................... 30 PROGRAF ................................................ 51 PROLASTIN............................................. 61 PROLEUKIN ............................................ 23 promethazine vc........................................ 61 PROMETRIUM........................................ 49 propafenone hcl......................................... 35

propantheline bromide .............................. 43 proparacaine hcl....................................... 56 Prophylactic ............................................. 22 propoxyphene hcl ........................................ 8 propoxyphene/acetaminophen .................... 8 propoxyphene-n/acetaminophen ................. 8 propranolol hcl ......................................... 35 propranolol hcl er ..................................... 35 propranolol/hydrochlorothiazide.............. 36 propylthiouracil ........................................ 51 PROQUAD ............................................... 54 Protectants ............................................... 44 Proton Pump Inhibitors ......................... 44 PROTOPIC ............................................... 41 PROVENTIL HFA ................................... 60 PROVIGIL................................................ 40 PULMICORT FLEXHALER ................... 59 Pulmonary Antihypertensives................ 61 pyrazinamide ............................................. 22 pyridostigmine bromide ............................ 22 quasense .................................................... 49 quinapril hcl .............................................. 39 quinapril/hydrochlorothiazide .................. 39 quinaretic .................................................. 39 quinidine gluconate cr .............................. 35 quinidine gluconate er .............................. 35 quinidine gluconate sa .............................. 35 quinidine sulfate........................................ 36 quinidine sulfate er.................................... 36 Quinolones ............................................... 13 QVAR ....................................................... 59 RABAVERT............................................. 54 RANEXA.................................................. 37 ranitidine hcl............................................. 44 RAPAMUNE............................................ 52 RAZADYNE............................................. 16 RAZADYNE ER....................................... 16 REBIF ....................................................... 53 REBIF TITRATION PACK ..................... 53 RECOMBIVAX HB ................................. 54 REGRANEX............................................. 42 RELENZA ................................................ 29 RELION 70/30.......................................... 32 RELION 70/30 INNOLET........................ 32 RELION N................................................ 33 RELION N INNOLET.............................. 33

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RELION R ................................................ 33 RELPAX ................................................... 21 REMICADE.............................................. 52 Renin-angiotensin-aldosterone System

Inhibitors ............................................. 38 REQUIP .................................................... 25 REQUIP XL.............................................. 26 RESCRIPTOR .......................................... 28 reserpine.................................................... 35 RESPIRATORY TRACT AGENTS ..... 58 Respiratory Tract Agents, Other........... 61 RESTASIS ................................................ 56 Retinoids .................................................. 24 RETROVIR IV INFUSION...................... 28 REVATIO ................................................. 61 REVLIMID ............................................... 23 REYATAZ................................................ 29 RHINOCORT AQUA............................... 59 RIASTAP .................................................. 34 ribasphere ................................................. 28 ribavirin .................................................... 28 RIDAURA ................................................ 53 RIFAMATE .............................................. 22 rifampin..................................................... 22 RIFATER.................................................. 22 RILUTEK.................................................. 40 rimantadine hcl ......................................... 29 RISPERDAL............................................. 26 RISPERDAL CONSTA............................ 26 RISPERDAL M-TAB............................... 26 risperidone ................................................ 26 RITUXAN................................................. 24 romycin...................................................... 13 ROTATEQ ................................................ 54 roxicet.......................................................... 8 ROZEREM................................................ 61 SAIZEN .............................................. 46, 47 SAIZEN CLICK.EASY............................ 47 Salicylates................................................. 55 SANDIMMUNE....................................... 52 SANDOSTATIN LAR DEPOT................ 50 SANTYL................................................... 42 Sedatives/Hypnotics ................................ 61 Selective Estrogen Receptor Modifying

Agents ................................................... 49 selegiline hcl ............................................. 26

selenium sulfide......................................... 42 SELZENTRY............................................ 29 SENSIPAR................................................ 50 SEREVENT DISKUS............................... 60 SEROMYCIN ........................................... 22 SEROQUEL.............................................. 27 SEROQUEL XR ....................................... 27 SEROSTIM............................................... 47 sertraline hcl ............................................. 18 silver sulfadiazine ..................................... 14 SIMCOR ................................................... 38 SIMPONI.................................................. 52 SIMULECT............................................... 52 simvastatin ................................................ 38 SINGULAIR ............................................. 59 Skeletal Muscle Relaxants ...................... 61 SKELETAL MUSCLE RELAXANTS . 61 sodium bicarbonate................................... 65 Sodium Channel Inhibitors .................... 15 sodium chloride................................... 45, 65 sodium chloride 0.45% viaflex.................. 65 sodium chloride 0.9% ............................... 45 sodium polystyrene sulfonate.................... 18 sodium sulfacetamide................................ 13 SOLARAZE.............................................. 42 SOLTAMOX ............................................ 23 SOMAVERT............................................. 50 sorine......................................................... 36 sotalol hcl .................................................. 36 sotalol hcl (af) ........................................... 36 SPIRIVA HANDIHALER........................ 60 spironolactone........................................... 37 spironolactone/hydrochlorothiazide ......... 37 sprintec 28................................................. 49 SPRYCEL................................................. 24 sps.............................................................. 18 sronyx ........................................................ 49 ssd.............................................................. 14 ssd af ......................................................... 14 stagesic........................................................ 9 STALEVO 100 ......................................... 26 STALEVO 150 ......................................... 26 STALEVO 200 ......................................... 26 STALEVO 50 ........................................... 26 stavudine ................................................... 28 STAVZOR ................................................ 15

85

STIMATE ................................................. 47 STRATTERA............................................ 40 STRIANT.................................................. 47 STROMECTOL........................................ 25 SUBOXONE............................................... 9 SUBUTEX .................................................. 9 SUCRAID ................................................. 43 sucralfate................................................... 44 sulf-10........................................................ 13 sulfacetamide sodium.......................... 14, 56 sulfacetamide sodium/prednisolone sodium

phosphate.............................................. 56 sulfadiazine ............................................... 14 sulfamethoxazole/trimethoprim................. 14 sulfamethoxazole/trimethoprim ds ............ 14 SULFAMYLON ....................................... 14 Sulfanamides ........................................... 14 sulfasalazine.............................................. 55 sulfatrim .................................................... 14 sulfazine .................................................... 55 sulfazine ec ................................................ 55 Sulfonamides ..................................... 13, 55 sulindac ..................................................... 10 sumatriptan ............................................... 21 SURMONTIL ........................................... 18 SUSTIVA.................................................. 28 SUTENT ................................................... 24 SYMBICORT ........................................... 60 SYMBYAX............................................... 27 SYMLIN ................................................... 30 SYNAREL ................................................ 50 SYNTHROID............................................ 49 SYPRINE.................................................. 18 TABLOID ................................................. 23 TAMIFLU................................................. 29 tamoxifen citrate....................................... 23 TARCEVA................................................ 24 TARGRETIN ............................................ 24 TARKA..................................................... 39 TASIGNA................................................. 24 TASMAR.................................................. 26 TAZORAC................................................ 42 taztia xt...................................................... 36 TEGRETOL-XR ....................................... 16 TEKTURNA............................................. 39 TEKTURNA HCT.................................... 39

terazosin hcl .............................................. 35 terbinafine hcl ........................................... 20 terbutaline sulfate ..................................... 60 terconazole ................................................ 20 TESTIM .................................................... 47 testosterone cypionate............................... 47 testosterone enanthate............................... 47 TESTRED ................................................. 47 TETANUS TOXOID ADSORBED ......... 54 TETANUS/DIPHTHERIA TOXOIDS-

ADSORBED ADULT .......................... 54 tetracycline hcl .......................................... 14 Tetracyclines............................................ 14 texacort...................................................... 46 THALOMID ............................................. 23 theochron .................................................. 60 theophylline cr........................................... 60 theophylline er........................................... 60 theophylline td........................................... 60 THERAPEUTIC

NUTRIENTS/MINERALS/ELECTROLYTES.................................................. 61

thermazene ................................................ 14 THIOLA.................................................... 45 thioridazine hcl ......................................... 27 thiothixene................................................. 27 THYROLAR-1.......................................... 49 THYROLAR-1/2 ...................................... 49 THYROLAR-1/4 ...................................... 49 THYROLAR-2.......................................... 50 THYROLAR-3.......................................... 50 ticlopidine hcl............................................ 35 TIKOSYN ................................................. 36 timolol maleate.................................... 22, 57 timolol maleate ophthalmic gel forming ... 57 TINDAMAX............................................. 25 tizanidine hcl............................................. 27 TOBRADEX............................................. 56 tobramycin sulfate..................................... 10 tobrasol ..................................................... 10 tolazamide ................................................. 30 tolbutamide................................................ 30 tolmetin sodium......................................... 10 TOPAMAX............................................... 15 TOPAMAX SPRINKLE........................... 15 topiramate................................................. 15

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topiramate sprinkle ................................... 15 torsemide................................................... 37 Toxicologic Agents .................................. 19 tpn electrolytes ftv ..................................... 65 tramadol hcl ................................................ 9 tramadol hydrochloride/acetaminophen..... 9 tranylcypromine sulfate............................. 17 TRAVASOL 2.75%/DEXTROSE 10%.... 65 TRAVASOL 2.75%/DEXTROSE 5%...... 65 travasol 3.5%/electrolytes......................... 65 TRAVASOL 4.25%/DEXTROSE 10%.... 65 TRAVASOL 5.5%/ELECTROLYTES .... 65 TRAVATAN............................................. 58 TRAVATAN Z......................................... 58 trazodone hcl............................................. 17 TRECATOR.............................................. 22 tretinoin..................................................... 23 trezix............................................................ 9 triamcinolone acetonide............................ 46 triamcinolone acetonide in absorbase ...... 46 triamcinolone in orabase .......................... 41 triamterene/hydrochlorothiazide .............. 37 TRICOR.................................................... 38 Tricyclics .................................................. 18 triderm....................................................... 46 trifluoperazine hcl..................................... 27 trifluridine ................................................. 28 trihexyphenidyl hcl .................................... 26 TRIHIBIT.................................................. 54 tri-legest fe ................................................ 49 TRILEPTAL ............................................. 16 trilyte......................................................... 43 trimethobenzamide hcl .............................. 19 trimethoprim........................................ 11, 14 trimethoprim sulfate/polymyxin b sulfate.. 11 trimethoprim/sulfamethoxazole ds ............ 14 trimipramine maleate................................ 18 trimox ........................................................ 12 trinessa ...................................................... 49 TRIPEDIA ................................................ 54 tri-previfem................................................ 49 TRISENOX............................................... 23 tri-sprintec................................................. 49 trivora-28 .................................................. 49 TRIZIVIR.................................................. 28 TROPHAMINE ........................................ 65

tropicacyl .................................................. 57 tropicamide ............................................... 57 TRUSOPT................................................. 57 TRUVADA ............................................... 28 TWINJECT............................................... 60 TWINRIX ................................................. 54 TYKERB................................................... 23 TYPHIM VI .............................................. 54 TYSABRI.................................................. 53 TYZEKA................................................... 28 u-cort ......................................................... 42 unithroid.................................................... 50 UROXATRAL.......................................... 45 URSO 250 ................................................. 43 URSO FORTE .......................................... 43 ursodiol ..................................................... 43 Vaccines.................................................... 54 VAGIFEM ................................................ 49 VALCYTE................................................ 28 valproate sodium....................................... 15 valproic acid ............................................. 15 vanacet ........................................................ 9 VANCOCIN HCL .................................... 11 VANCOCIN HCL ISO-

OSMOTICDEXTROSE........................ 11 vancomycin hcl.......................................... 11 vandazole .................................................. 11 VANTAS .................................................. 50 VAQTA..................................................... 54 VARIVAX ................................................ 55 Vasodilators ............................................. 39 veetids........................................................ 12 VELCADE................................................ 23 venlafaxine hcl .......................................... 18 VENTAVIS............................................... 61 VERAMYST............................................. 59 verapamil hcl............................................. 36 verapamil hcl er ........................................ 36 VESICARE............................................... 44 VEXOL..................................................... 58 VFEND ..................................................... 20 VFEND IV ................................................ 20 VIDAZA ................................................... 23 VIDEX ...................................................... 28 VIDEX EC ................................................ 28 VIMPAT ................................................... 16

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VIMPAT SOLUTION .............................. 16 VIOKASE................................................. 43 VIOKASE 16 ............................................ 43 VIOKASE 8 .............................................. 43 VIRACEPT............................................... 29 VIRAMUNE............................................. 28 VIREAD.................................................... 28 VISTIDE................................................... 28 vitamin/mineral, misc................................ 65 Vitamins ................................................... 65 VIVACTIL................................................ 18 VIVAGLOBIN.......................................... 52 VIVELLE-DOT ........................................ 49 VIVOTIF BERNA.................................... 55 VYTORIN................................................. 38 warfarin sodium ........................................ 33 XALATAN ............................................... 58 XOLAIR.................................................... 61 XYREM .................................................... 40 YF-VAX.................................................... 55 ZANOSAR................................................ 23 ZAVESCA ................................................ 43 zazole......................................................... 20

ZEMAIRA ................................................ 61 ZEMPLAR................................................ 56 ZENAPAX................................................ 52 ZERIT ....................................................... 28 zerlor ........................................................... 9 ZETIA ....................................................... 38 ZIAGEN.................................................... 28 zidovudine ................................................. 28 ZMAX....................................................... 13 ZOLINZA ................................................. 23 zolpidem tartrate....................................... 61 ZOMIG...................................................... 22 ZOMIG ZMT............................................ 22 zonisamide................................................. 14 ZORBTIVE............................................... 47 ZOSTAVAX ............................................. 55 zovia 1/35e ................................................ 49 zovia 1/50e ................................................ 49 ZYFLO CR ............................................... 59 ZYPREXA ................................................ 27 ZYPREXA ZYDIS ................................... 27 ZYVOX..................................................... 11

Documents

Citrus Health Care 2009 Formulary (List of Covered Drugs) › reports › cmsd › 2009 › ... · and/or step therapy restrictions on a drug or move a drug to a higher cost -sharing